All Trust staff, agency staff working for the Trust, Non-Executives, Contractors engaged by the Trust

Transcription

1 Policy: Sustainable Development Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke Helen Payne Head of Soft Facilities Management Date of draft Reviewed October 2013 Dates of consultation period June July 2009 Date of ratification 9 Ratified by Executive Directors Group Date of issue October 2009 Date for review March 2014 Target audience All Trust staff, agency staff working for the Trust, Non-Executives, Contractors engaged by the Trust Policy Version and advice on document history, availability and storage Version Three Available on Policy website Archives (from 2001) stored by Risk Management Department. This Policy supersedes the following earlier documents: Environmental Management Policy; Energy Management & Efficiency Policy & Strategy; Water Management & Efficiency Policy & Strategy Sustainable Development Policy (Version 3) Page 1 of 20

2 Contents: Section Page Flow Chart (not included) 3 1 Introduction 4 2 Scope of this policy 4 3 Definitions 4 4 Purpose of this policy 5 5 Duties Reasons for having a Policy Energy & carbon management Procurement & food Low carbon travel, transport & access Water Waste Designing the built environment Organisational & workforce development Role of partnership & networks Governance Finance 10 7 Dissemination, storage and archiving 11 8 Training and other resource implications for this policy 11 9 Audit, monitoring and review Implementation plan Links to other policies, standards and legislation Contact details References 13 Appendix A Sustainable Development Policy Statement 14 Supplementary Sections: Section A Equality impact assessment form 15 Section B Human rights act assessment checklist 18 Section C Development and consultation process 20 Sustainable Development Policy (Version 3) Page 2 of 20

3 Flowchart Where appropriate, a flowchart or diagram which summarises the policy and processes to be followed should be included here. It is recommended that this it is placed here at the start of the document for ease of access. However; this must not imply that staff should only refer to the flowchart and not the text of the policy. The flowchart should include references to sections of the policy to assist staff in finding the right place in the full document. Sustainable Development Policy (Version 3) Page 3 of 20

4 1. Introduction The NHS needs to be well prepared for the future and ensure future health services play a leading part in a sustainable society, despite the challenges of climate change. The Trust needs to recognise that its activities have effects on the environment and consequently on the health and well being of the community it serves, and take actions to ameliorate these where practicable. It is also needs to meet the requirements of the Environmental Protection Act 1990, other relevant legislative/regulatory requirements, and comply with strategies issued by the NHS Executive or similar agencies e.g. Saving Carbon, Improving Health (NHS Carbon Reducing Strategy for England, January 2009). As part of this strategy, the NHS has an aim of achieving a 10 per cent reduction in its 2007 carbon footprint by The Trust must be able to contribute to this reduction. The strategy also recommends every NHS organisation should sign up to the Good Corporate Citizenship Assessment Model [Online]. This Policy does not specifically address this recommendation but the Trust would be unable to sign up to the model without having a Sustainable Development Policy. The Care Quality Commission (CQC), as part of its strategic planning, will be considering how it makes environmental and public health issues an appropriate and meaningful part of its assessment criteria. The Department of Health (DH) is committed to including sustainable development in the CQC s performance assessment framework for the NHS. The Operating Framework for the NHS in England 2009/10 recommends that every organisation should ensure it measures and progressively reduces its own carbon footprint. There are now legally binding UK Government targets to reduce carbon emissions by 80% by 2050 compared to 1990 levels (Climate Change Act 2008). 2. Scope of this policy This Policy will apply across the whole Trust. Although many of the relevant activities are directly managed by the Trust s support directorates e.g. Facilities, I.T., successful implementation will depend on the engagement of all staff and services. 3. Definitions Sustainable development is defined as any construction that can be maintained over time without damaging the environment; development balancing near-term interests with the interests of future generations (1). Alternative definitions include the integration of environmental, social, political and economic considerations and impacts within decision making or meeting the needs of people today without compromising the ability to meet the needs of people in the future (Sustaining a Healthy Future) Environmental management is defined as an attempt to control human impact on and interaction with the environment in order to preserve natural resources (1). It is a term Sustainable Development Policy (Version 3) Page 4 of 20

5 which encompasses a very wide range of possible actions including but not confined to, management of: o Emissions to air o Noise and odour o Discharges to water and water consumption o Disposals to land o Waste management o Contractor and tenant related issues o Emergencies, accidents and abnormal working conditions o Energy management o Transport and distribution o Raw materials and supplier management o Site storage o Packaging o Awareness training and communication Carbon footprint is defined as a measure of the amount of carbon dioxide produced by a person, organisation or location at a given time (1) 4. Purpose of this policy The purpose of the sustainable development policy is: To identify the actions the Trust will take, in working towards managing its environmental impacts The objectives of the policy are that the Trust will continually aim to manage its environmental impacts wherever possible (having taken value for money into account) by: Conserving water, energy and other resources Undertaking proper disposal of clinical and other waste, and taking steps to prevent and minimise waste production Monitoring discharges and emissions to air, land and water, reducing pollution and greenhouse gases Selecting environmentally acceptable products Promoting re-use and recycling of goods and materials Encouraging suppliers, contractors and others to adopt good environmental standards, and selecting local suppliers where practicable Maintaining the Trust estate in an environmentally sound manner, including protection of natural habitats Promoting good practice in use of transport services, encouraging and support healthy transport solutions Educating and training staff, involving them in developing new ideas and initiatives Communicating with staff and others about policies, practices and improvements made The intended outcomes will be: Ability to meet legislative, regulatory and strategic requirements Ability to contribute to the NHS carbon reduction target Ability to demonstrate the Trust s sustainable development commitment to other organisations A better engaged and informed staff who actively contribute to the outcomes Sustainable Development Policy (Version 3) Page 5 of 20

6 5. Duties Overall responsibility The Chief Executive has overall responsibility for sustainable development, and will delegate a named Executive Director to have responsibility for sustainability issues Non-Executives responsibilities A Non-Executive Board member should be identified as a Sustainability Champion (or Corporate Citizen Champion) to promote good carbon governance as a corporate responsibility of the whole Board (this may be combined with the Design Champion role if necessary) Management responsibilities Implementation of the Policy will be the responsibility of Directors/Heads of Service with advice and support from Facilities Directorate managers/other support services managers as appropriate Staff responsibilities Staff will be expected to: Co-operate in the implementation of sustainable development objectives Assist in meeting sustainability targets Participate in training initiatives 6. Specific details 6.0 Reasons for having a Policy Saving Carbon, Improving Health has identified 6 reasons why NHS organisations need to act now to understand, manage and reduce their carbon footprint: The new legally binding Government framework and national targets The strength of the scientific evidence to act now on climate change The health co-benefits now for patients and populations, and for the health system itself The importance of cost reductions and energy resilience The willingness and commitment of NHS organisations and staff to act now The need for the NHS to be a leading public sector exemplar now This strategic document has focused on delivery based within 10 key areas; the remainder of Section 6 is broken down into these 10 areas for ease of monitoring against targets. The 10 key areas are: 1. Energy and carbon management 2. Procurement and food 3. Low carbon travel, transport and access 4. Water 5. Waste 6. Designing the built environment 7. Organisational and workforce development 8. Role of partnership and networks 9. Governance 10. Finance Sustainable Development Policy (Version 3) Page 6 of 20

7 6.1 Energy and carbon management Consumption of energy will be minimised consistent with operational needs and while maintaining a safe working environment. This will include a minimum working temperature during colder periods, and provision of cool rooms which are accessible to vulnerable patients during periods of excessively hot weather, as per NHS guidance We will work with The Carbon Trust or other specialist advisors to identify energy-saving opportunities and implement these as funds permit Energy consumption will be monitored as a minimum for individual premises, and where possible for individual service areas/departments, especially where there is above average consumption e.g. IT server rooms, kitchens Energy will be purchased from sustainable sources e.g. energy from waste (EFW); wind power, if this provides value for money Energy implications of new services, facilities or equipment will be assessed as part of the business case option appraisal, and the introducing service required to identify funding and work with the Facilities Directorate on ways to minimise energy needs Existing premises will be upgraded to minimise energy consumption e.g. double glazing, insulation as funds permit, including capital-funded spend to save schemes Use of premises rationalised where possible Revised service models of healthcare delivery (services closer to home rather than buildings-based) are expected to support energy management in the longer term All staff to be encouraged to take much greater responsibility for carbon management Campaigns to be introduced jointly with Staff Side to promote staff responsibility and the removal of non-essential, energy-intensive equipment We will aim to introduce a dedicated sustainable development manager funded via efficiency savings Any new build capital developments should be option assessed on a whole life cost basis to ensure low carbon options are included 6.2 Procurement and food The Trust is part of a regional supplies collaborative and will continue to work within this arrangement plus with NHS PASA and NHS Supply Chain, to improve sustainable and low carbon procurement in partnership with suppliers The Trust will purchase food from local suppliers where this provides value for money The Trust will aim to serve healthy and tasty food appropriate for patients nutritional needs; food-related ill health is known to cost the NHS billions of pounds per year The Trust will continue to manage its levels of food waste as this is an important action in reducing the overall carbon footprint; this will require increased co-operation between clinical and support services The Trust will promote the use of supplies made from recycled, reused, biodegradable or similarly environmentally friendly substances provided these give appropriate quality and value for money 6.3 Low carbon travel, transport and access This section should be read in conjunction with the Trust s Transport Policy. The Trust will: Develop and implement a sustainable travel plan, having regard for the geographically dispersed nature of Trust premises and the need to provide community teams who visit Sustainable Development Policy (Version 3) Page 7 of 20

8 patients in their homes etc. Note: all NHS organisations should have a Board approved travel plan in place by 2010 Ensure all main sites can offer facilities to support active travel e.g. cycle storage, showers & changing rooms Consider how it can make better use of training/equipment which minimises the need for travel e.g. e-based training; video conferencing Ensure the Trust s flexible working policy includes opportunities for home working or other arrangements which lessen the need for staff to travel, where appropriate Utilise more environmentally friendly vehicles e.g. dual fuel, as fleet replacements permit Investigate systems which would aide increased fleet productivity e.g. vehicle tracking 6.4 Water Continue current work with a specialist consultant to reduce water consumption Review practices e.g. legionella flushing, to ensure any extraneous use of water is reduced commensurate with the level of risk to be managed Ensure all refurbishments/new developments have the most water-efficient fixtures and fittings provided as standard Introduce retro-fitted water efficiency measures where these have a provable pay-back period Phase out any bottled water machines currently in use within the Trust; ensure tap water is used wherever practicable (including for meetings or other events) or substitute plumbed-in water coolers (with suitable cleaning and maintenance arrangements) Ensure kitchens for use by staff are fitted with instant demand hot water wall mounted boilers, and kettles phased out (also reduces energy consumption) 6.5 Waste This section should be read in conjunction with the Trust s Waste Management Policy. The Trust will: Ensure it undertakes waste management in line with all legislative or other regulatory requirements Monitor the quantity and cost of its different waste streams and set targets to manage and reduce these over time Implement a range of recycling initiatives including e.g. paper, mobile telephones, obsolete IT equipment Works towards reducing food waste (see 6.2 above) and in the longer term consider sustainable disposal of food waste 6.6 Designing the built environment This section relates mainly to new buildings and major refurbishment schemes. Where such opportunities arise, the Trust will need to take into account the recommendations from Savings Carbon, Improving Health which indicate a need to take a whole life costing approach design and build of healthcare buildings must encourage sustainability including transport, delivery of service and community engagement, and buildings need to be adaptable to support change. Designing in of formal carbon reduction requirements will be essential. Sustainable Development Policy (Version 3) Page 8 of 20

9 Any new build or refurbishment schemes with a value of over 2M are required to include a BREEAM Healthcare Assessment as part of the Business Case, or the business case will not be supported (New builds must achieve a rating of Excellent; refurbishments must achieve a rating of Very Good). The Trust s existing estate will be improved where possible, to reduce the carbon footprint (see Section 6.1 above) The grounds and gardens surrounding the Trust s buildings will be maintained in an environmentally sound manner, including protection of natural habitats 6.7 Organisational and workforce development The Trust will consider ways of improving the knowledge base of its staff so that they are empowered and motivated to take action towards sustainability and carbon reduction. This should include: Working in partnership with staff side representatives Identifying staff who are willing to be volunteer environmental champions Providing a range of training and information e.g. induction training materials, articles in newsletters, specialised training in energy management, procurement and travel for key staff An Staff Action Group should be set up to implement the Board-approved Sustainability Action Plan/actions arising from this Policy, comprising champions (as above); Staff Side Environmental Representatives; Management representatives and other interested parties The Trust will consider including responsibility for sustainability and carbon governance on all job descriptions, including Chief Executive and Director level posts The Facilities Directorate will plan to employ a dedicated sustainable development manager who will play a lead role in wider sustainability issues across the Trust The Trust s Travel Plan (part of the Transport Policy) will consider how staff can minimise the impact of travel in a variety of ways The Trust will work with partners e.g. Job Centre Plus; Learning Skills Council; local colleges to create entry level jobs and training for young people; the unemployed, and service users 6.8 Role of partnership and networks To assist it in making an impact on climate change, all NHS organisations need to work with partners to develop and promote renewable energy sources, sustainable transport for staff and patients, and procurement of goods and services that are sustainable and low carbon. In particular, the Trust should work in partnership with the Local Authority within the framework of the Local Strategic Partnership (LSP) Sustainable Development Policy (Version 3) Page 9 of 20

10 The Trust will also work in partnership with e.g. suppliers, agencies and contractors to promote the need for a low carbon society 6.9 Governance The Trust will consider signing up to the NHS Good Corporate Citizenship Assessment Model, which includes production of a Board approved Sustainable Development and Carbon Management Plan, setting out clear targets for measuring, monitoring and reducing carbon emissions. Note: by 2009, all NHS organisations should have a Board approved strategy/plan in place The Trust will utilise its ability as a Foundation Trust to better understand (via its Governors) the need to play an exemplar role in carbon reduction and sustainability within the local community, and to make longer term investments in sustainability where there are good returns on investment e.g. spend to save schemes The Trust s Annual Plan should include a measure of carbon emissions, initially based on ERIC data, but in the longer term developed to include various measures of direct and indirect carbon emissions A Non-Executive Director will be identified as Sustainability Champion Carbon management must be incorporated into whole-organisation risk assessments/risk management/risk register (know as carbon governance ) 6.10 Finance The Trust will investigate the possibility of utilising funds which become available specifically to support energy efficiency or similar initiatives e.g. Salix Finance (2); DH energy funds 7. Dissemination, storage and archiving Available on Intranet by Integrated Governance Department within 1 week of ratification Electronic copy disseminated via to all staff and put on Trust electronic notice board by Head of Soft FM after Policy placed on Intranet Archived copies stored by Risk Management Department Version Control responsibility of Head of Soft FM 8. Training and other resource implications for this policy Training & Development Need to create an information pack to be included with Trust corporate induction materials Ad hoc specialised training for specific Facilities Directorate managers happens as a normal part of the Directorate s training plans but no funds available Sustainable Development Policy (Version 3) Page 10 of 20

11 Staff Side representative(s)/ environmental champions may benefit from additional training to support their roles Other resource implications New sustainable development manager role in Facilities Directorate (Estate Services). No funding. Intention is to create funding using efficiency savings generated through energy reduction/ green initiatives/ spend to save schemes Anticipated savings & efficiencies Reduction in use of energy (including transport fuels) Reduction in use of water Reduction in % of waste being disposed of via landfill Increase in % of waste being recycled/re-used Reduction in carbon footprint of suppliers/more effective use of local suppliers Better use of available employment pool Reduction in food waste Reduction in inefficient/inappropriate purchases e.g. bottled water machines A more sustainable organisation, better placed to meet future challenges 9. Audit, monitoring and review Audit & Monitoring ERIC data (annual comparison figures) Monitoring of waste streams (annual) Monitoring of food waste (annual) Facilities Directorate Performance Reviews (6 monthly) Adoption of Good Corporate Citizenship Model (annual) Production of a Sustainable Development & Carbon Management Plan (annual) This Policy should be monitored via the Service and Business Development Group Review This policy should be reviewed in 2 years, or earlier if there are any changes which necessitate review e.g. changes in legislation or DH strategic requirements 10. Implementation plan Action/Task Responsible Person Deadline Progress update Put new policy onto Intranet Chief Nurse After policy Sustainable Development Policy (Version 3) Page 11 of 20

12 and remove old policies ratified (?30/9/2009) Make Trust staff aware of Head of Soft FM Ditto above new policy Create induction pack Head of Soft FM 31/03/2010 Include induction pack into Director of Human 31/03/2010 corporate induction process Resources Commence partnership working with Unison Environmental Steward Director of Facilities/Head of Estate Services/Head 31/12/2009 Consider any need for additional training for Unison representative(s) and/or environmental champions Develop new job role of Trust Sustainable Development Manager Development & implement plan to remove nonessential, energy intensive equipment + phasing out of bottled water machines Introduce responsibility for sustainability & carbon governance on all Job Descriptions Sign up to Good Corporate Citizenship Assessment Model Include measures of carbon emissions in Trust Annual Plan Investigate use of specialist funds for energy efficiency projects of Soft FM Head of Estate Services/Head of Soft FM Head of Estate Services Head of Estate Services/Head of Soft FM Director of Human Resources 31/03/ /03/ /06/ /06/2010 Director of Facilities/ 30/06/2010 Executive Director of Operations Director of Facilities/ 30/06/2010 Director of Planning & Performance Director of Facilities 30/06/ Links to Other Policies Infection Prevention & Control Waste Management Control of Substances Hazardous to Health (C.O.S.H.H.) Transport Water Policy Control of Legionella Sustainable Development Policy (Version 3) Page 12 of 20

13 12. Contact details Title Name Phone Head of Soft Facilities Helen Payne Management Director of Facilities Clive Lancaster Head of Estate Services Mark Gamble References Legislation The Environmental Protection Act 1990 The Climate Change Act 2008 Government policy Saving Carbon, Improving Health NHS Carbon Reduction Strategy for England, January 2009 Available at Department of Health, The Operating Framework for 2009/10 for the NHS in England: HMSO Taking the long term view: the Department of Health s strategy for delivering sustainable development Available at: Online resources The Sustainable Development Commission, Good Corporate Citizenship Assessment Model Available at: Sustaining a Healthy Future taking action on climate change: Special Focus on the NHS Available at (1) Definitions of environmental management terms Available at: [accessed ] (2) Salix Finance Available at [accessed ] Sustainable Development Policy (Version 3) Page 13 of 20

14 Appendix A - Sustainable Development Policy Statement Our Commitment The Trust recognises that its activities have effects on the environment, and consequently, on the health and well being of the community it serves. The Trust will work towards reducing any adverse environmental impact from its activities while continuing to provide a range of high quality healthcare services. The Trust will as a minimum meet the requirements of all relevant legislation, and adopt and promote good practice wherever practicable Our Responsibilities The Chief Executive has overall responsibility for sustainable development. The Trust will also identify a named Executive Director with delegated responsibility for sustainability, and a Non-Executive Director to act as Sustainability Champion. All Trust staff are expected to co-operate in the implementation of sustainable development procedures, the meeting of targets, and to participate in training to raise awareness of good practice Our Objectives The environmental impacts caused by Trust activities include: consuming energy and other resources; purchasing goods; producing waste, effluent and emissions to the atmosphere and use of vehicles. We will manage our environmental impacts wherever possible by: Complying with all legislative and regulatory requirements Conserving water, energy and other resources Properly disposing of clinical and other waste; requiring contractors to comply with Trust waste management standards; taking steps to prevent and minimise waste; and reusing and recycling goods Monitoring discharges and emissions to air, land and water, reducing pollution and greenhouse gases Selecting environmentally acceptable products and services where these also represent value for money, and working with contractors and suppliers towards adopting good sustainable development standards Maintaining the Trust estate in an environmentally sound manner, including protection of natural habitats Promote good practice in use of transport services, encouraging and supporting healthy transport solutions Educating and training staff to help them meet sustainable development requirements, and encourage them to be involved in developing new ideas and initiatives Communicating with staff and others about our policies and practices, and the improvements we make Signed (Chief Executive) Date Sustainable Development Policy (Version 3) Page 14 of 20

15 Supplementary Section A - Stage One Equality Impact Assessment Form Please refer back to section 6.5 for additional information 1. Have you identified any areas where implementation of this policy would impact upon any of the categories below? If so, please give details of the evidence you have for this? Grounds / Area of impact People / Issues to consider Type of impact Description of impact and reason / Negative (it could disadvantage) Positive (it could advantage evidence Race People from various racial groups (e.g. contained within the census) No impact identified Gender Male, Female or transsexual/transgender. Also consider caring, No impact identified parenting responsibilities, flexible working and equal pay concerns Disability The Disability Discrimination Act 1995 defines disability as a physical or mental impairment which has a substantial and longterm effect on a persons ability to carry out normal day-to-day activities. This includes sensory impairment. Disabilities may be visible or non visible Section 6.7 Reinforces the Trust s commitment to create employment opportunities for service users Sexual Orientation Lesbians, gay men, people who are bisexual No impact identified Age Children, young, old and middle aged people Section 6.7 Reinforces the Trust s commitment to work with partner organisations to create employment opportunities for young people Religion or belief People who have religious belief, are atheist or agnostic or have a philosophical belief that affects their view of the world. Consider faith categories individually and collectively when considering possible positive and negative impacts. No impact identified Sustainable Development Policy (Version 3) Page 15 of 20

16 2. If you have identified that there may be a negative impact for any of the groups above please complete questions 2a-2e below. 2a. The negative impact identified is intended OR 2b. The negative impact identified not intended 2c. The negative impact identified is legal OR 2d. The negative impact identified is illegal OR (see 2e) (i.e. does it breach antidiscrimination legislation either directly or indirectly?) 2e. I don t know whether the negative impact identified is legal or not (If unsure you must take legal advice to ascertain the legality of the policy) 3. What is the level of impact? HIGH - Complete a FULL Impact Assessment (see end of this form for details of how to do this) MEDIUM - Complete a FULL Impact Assessment (see end of this form for details of how to do this) LOW - Consider questions 4-6 below 4. Can any low level negative impacts be removed (if so, give details of which ones and how) 5. If you have not identified any negative impacts, can any of the positive impacts be improved? (if so, give details of which ones and how) 6. If there is no evidence that the policy promotes equality and equal opportunity or improves relations with any of the above groups, could the policy be developed or changed so that it does? 7. Having considered the assessment, is any specific action required - Please outline this using the pro forma action plan below Sustainable Development Policy (Version 3) Page 16 of 20

17 (The lead for the policy is responsible for putting mechanisms in place to ensure that the proposed action is undertaken) Issue Action proposed Lead Deadline 8. Lead person Declaration: 8a. Stage One assessment completed by : Helen Payne. (name). (signature) (date) 8b. Stage One assessment form received by Patient experience and Equality Team..(date) 8c. Stage One assessment outcome agreed. (sign here).... (Head of Patient Experience and Equality) OR (date agreed) 8d. Stage One assessment outcome need review.. (sign here).... (Head of Patient Experience and Equality).. (date returned to policy lead for amendment) (if review required please give details in text box below) If a full EQIA is required the stage 1 assessment form should be retained and a completed EQIA report submitted to the relevant governance group for agreement by the chair. The chair will forward the completed reports to the Patient Experience and Equality team for publication. Any questions relating to the completion of this form should be directed to the Head of Patient Experience and Equality. Sustainable Development Policy (Version 3) Page 17 of 20

18 Supplementary Section B - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this policy breaches a persons Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the policy or any procedures in the policy, are based on a local decision which impact on individuals, then you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site (relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your policy based on and in line with the current law (including caselaw) or policy? Yes. No further action needed. No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person Sustainable Development Policy (Version 3) Page 18 of 20

19 Human Rights Assessment Flow Chart Complete text answers in boxes and highlight your path through the flowchart by filling the YES/NO boxes red (do this by clicking on the YES/NO text boxes and then from the Format menu on the toolbar, choose Format Text Box and choose red from the Fill colour option). Once the flowchart is completed, return to the previous page to complete the Human Rights Act Assessment Form. 1.1 What is the policy/decision title? Sustainable Development Policy What is the objective of the policy/decision? That the Trust will manage its environmental impacts Who will be affected by the policy/decision? All Trust staff & agency staff, contractors, Non-Executives 1 Flowchart exit Will the policy/decision engage anyone s Convention rights? YES Will the policy/decision result in the restriction of a right? 2.2 YES 2.1 NO NO There is no need to continue with this checklist. However, o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o Legal advice may still be necessary if in any doubt, contact your lawyer o Things may change, and you may need to reassess the situation Is the right an absolute right? 3.1 YES NO 4 The right is a qualified right Is the right a limited right? YES 3.2 Will the right be limited only to the extent set out in the relevant Article of the Convention? 3.3 NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? YES NO Policy/decision is likely to be human rights compliant BUT Policy/decision is not likely to be human rights compliant please contact the Head of Patient Experience, Inclusion and Diversity. Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. You should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right. Access to legal advice MUST be authorised by the relevant Executive Director or Associate Director for policies (this will usually be the Chief Nurse). For further advice on access to legal advice, please contact the Complaints and Litigation Lead. Sustainable Development Policy (Version 3) Page 19 of 20

20 Supplementary Section C - Development and consultation process o Who was involved in developing the policy and any guidance followed. o Head of Soft Facilities Management o Guidance followed: see references in main document o Groups and individuals consulted (including staff side groups and service user / carer involvement) o Director of Facilities o Head of Estate Services o Technical Support Officer o Maintenance Development Officer o Head of Procurement & Logistics o UNISON Environmental Steward o Capital Development Manager o Deputy Head of Human Resources o Head of Patient Experience, Inclusion & Diversity o Any changes made as a result of the consultation process. The draft has been amended to reflect the wider aspects of sustainable development and what this means. The role of a responsible Non-Executive has been added. The need for a representative Staff Action Group (joint with Staff & Management side representatives) has been added. The need to introduce carbon governance has been added. The role of NHS procurement agencies has been clarified. o Which governance group approved the document o Quality & Risk Group o Dates for consultation and approval o Consultation dates: June July 2009 o Approval date: 9 Sustainable Development Policy (Version 3) Page 20 of 20