Equality, Diversity & Inclusion strategy (2016-2017) Our vision is to deliver the best care by the best people, and to be inclusive and accessible across our diverse community. We want to become a leader in the field of promoting equality, valuing diversity and tackling health inequalities, whilst building strong and sustainable partnerships with local stakeholders. Our patients and workforce represent a vast array of people from diverse cultures, backgrounds and experiences. Our objective is to improve services and experiences for everyone, but particularly those who belong to vulnerable and protected groups. We aim to achieve this by assessing health inequalities, and providing an inclusive, accessible environment - free from discrimination and where diversity is valued - for people who use and work in the Trust. Equality Act 2010 The Equality Act 2010 legally protects people from discrimination in the workplace and in wider society. Laws under the Equality Act set out that every patient should be treated as an individual and with respect and dignity. The NHS already has clear values and principles about equality and fairness, as set out in the NHS Constitution, and the laws under the Equality Act 2010 reinforce many of these. Definitions The Equality Act 2010 defines nine protected diversity characteristics: Age Disability Gender reassignment Marriage or civil partnership Pregnancy & maternity Race (ethnic or national origins, colour or nationality) Religion or belief (including absence of belief) Sex/gender Sexual orientation. It also protects people who are at risk of discrimination by association or perception. This could include, for example, a carer who looks after a disabled person. Our definition of diversity is much broader and includes differences geography, education, first language, employment and socioeconomic status.
It also includes people who fall into Inclusion Health groups, who might experience difficulties in accessing, and benefitting from, the NHS. These other disadvantaged groups can include, but are not limited to: People who are homeless People who live in poverty People who are long-term unemployed People in stigmatised occupations (such as women and men involved in prostitution) People who misuse drugs People with limited family or social networks People who are geographically isolated Public Sector Equality Duty The Equality Act 2010 imposes a general equality duty on public bodies and others carrying out public functions. It requires the Trust to have due regard to the need to: eliminate unlawful discrimination, harassment & 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 those who do not share it foster good relations between different people who share a relevant protected characteristic and those who do not share it. As a public body, we have to consider all individuals when carrying out our day-to-day work: in shaping policy, in delivering services and in relation to our own employees. The Equality Act 2010 also imposes specific equality duties, which are intended to enable better performance of the general equality duty. These specific duties require the Trust to: publish relevant, proportionate information showing compliance with the Equality Duty set specific, measurable equality objectives Our goals: Equality Delivery System (EDS2) Our approach to being inclusive is guided by EDS2, a national framework designed to help NHS organisations - in partnership with local stakeholders - review and improve their performance for people with characteristics protected by the Equality Act 2010, and to support them in meeting their Public Sector Equality Duty. It supports the improvement of services for the community and the creation of a better working environment. EDS2 is a generic tool designed to measure NHS equality performance against four broad goals, which relate to issues that matter to people who use and work in the NHS. These are: 1. Better health outcomes 2. Improved patient access & experience 3. Representative and supported workforce 4. Inclusive leadership
Amongst other things, these goals support the delivery of the NHS Outcomes Framework, the NHS Constitution, and the Care Quality Commission s (CQC s) key inspection questions set out in Raising standards, putting people first our strategy for 2013 to 2016. Our aims The four goals defined by EDS2 encompass 18 preferred outcomes that relate to issues that matter to people who use, and work in, the NHS. 1. Better health outcomes Services are commissioned, procured, designed and delivered to meet the health needs of local communities Individual people s health needs are assessed and met in appropriate and effective ways Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse Screening, vaccination and other health promotion services reach and benefit all local communities 2. Improved patient access & experience People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds People are informed and supported to be as involved as they wish to be in decisions about their care People report positive experiences of the NHS People s complaints about services are handled respectfully and efficiently 3. Representative and supported workforce Fair NHS recruitment and selection processes lead to a more representative workforce at all levels The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations Training and development opportunities are taken up and positively evaluated by all staff When at work, staff are free from abuse, harassment, bullying and violence from any source Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives Staff report positive experiences of their membership of the workforce 4. Inclusive leadership Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination
Our Equality, Diversity and Inclusion Action Plan describes our approach to the delivery of these outcomes. Measuring our success: EDS2 grading events For most outcomes the key question is, how well do people from protected groups fare compared with people overall? There are four grades: Undeveloped there is no evidence one way or another for any protected group of how people fare Developing evidence shows that the majority of people in only two or less protected groups fare well Achieving evidence shows that the majority of people in six to eight protected groups fare well Excelling evidence shows that the majority of people in all nine protected groups fare well EDS2 is not a self-assessment tool. Our performance will be assessed and graded following discussion with local stakeholders and independent third parties (e.g. other NHS organisations, Healthwatch organisations and national bodies such as Stonewall and the Black and Minority Ethnic Health and Social Care Network). Typically local stakeholders comprise: patients, carers, members of local community groups, other members of the public, representatives of local voluntary and community organisations, NHS staff and representatives of staff-side organisations. By working in partnership with voluntary and community sectors, we can engage more effectively with a wide range of local communities, including marginalised and seldom-heard groups. Our success will be measured by the progressive development towards achieving Excelling in the Equality Delivery System 2 (EDS2) grading. Next steps Our aim is to develop and embed a holistic view of equality, diversity, inclusion and human rights - where individual differences are understood, valued and celebrated - across the organisation. We recognise that work on EDS2 in particular, and equality in general, will only make an impact when it is located within mainstream business and governance structures, and when NHS Boards and senior leaders lead the way, and where the emphasis is on inclusive services and inclusive workforces. The first step is to approve and embed an Equality, Diversity and Inclusion Strategy for our Trust. This strategy will be owned by a newly created Equality, Diversity and Inclusion Committee, which will report to the Quality and Safety and Committee. It will also support the work of the Workforce, Remuneration, Charitable Funds and Audit and Risk Committees.
During its infancy, the Committee shall meet on a monthly basis in order to maintain momentum. The frequency of the meetings will be reviewed in December 2016. The strategy is supported by a two-year action plan that describes how we will deliver our goals and objectives. Significant actions for 2016 include: Prepare an EDS2 Summary Report and publish the results. Complete an EDS2 grading event and publish the results. Increase our understanding of whom our community includes and what their specific needs are. This will be achieved through improved data collection and evidence gathering, and increased community engagement. Implement an accessible information plan in order to comply with the Accessible Information Standard. Assess our performance against the Workforce Race Equality Standard (WRES), which requires us to take action to ensure employees from black and ethnic minority (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace. The results of this assessment much be published. The strategy and action plan will evolve as we gain a better understanding of the key issues facing our Trust. Therefore, the strategy and action plan will be monitored and reviewed by members of the Equality, Diversity and Inclusion Committee, along with the Trust s Equality, Diversity and Inclusion Project Lead and other key members of staff, on a monthly basis during 2016. Appendices 1. Infographic showing proposed location of Equality, Diversity and Inclusion Committee in overall Governance Committee structure. 2. Terms of Reference for Equality, Diversity and Inclusion Committee. 3. Additional information about EDS2. 4. Additional information about WRES.
Appendix 1: Governance Committee Structure Charitable Funds Audit & Risk Committee Quality & Safety Committee Finance & Performance Committee Remuneration Committee Workforce Committee Trust Board Hospital Management Committee Equality, Diversity & Inclusion Committee Hospital Senate Medical Director Director of Nursing, Midwifery & Quality Chief Operating Officer Director of HR Chief Finance Officer Director of Estates & Facilities Surgical Division Performance Review Group Medicine Division Performance Review Group Corporate Performance Review Group
Appendix 2: TERMS OF REFERENCE EQUALITY, DIVERSITY & INCLUSION COMMITTEE (sub-committee of Board) References to the Committee shall mean Equality, Diversity & Inclusion Committee (EDI Committee). References to the HHCT shall mean Hinchingbrooke Health Care NHS Trust. References to EDI shall mean equality, diversity and inclusion. References to HR shall mean Human Resources. 1.0 Statement of Purpose Hinchingbrooke Health Care NHS Trust aims to deliver the best care by the best people, and to be inclusive and accessible across our diverse community. We aim to achieve this by assessing health inequalities, and providing an inclusive, accessible environment - free from discrimination and where diversity is valued - for people who use and work in the Trust. The purpose of the Committee is to: ensure HHCT complies with the Equality Act 2010, the Public Sector Equality Duty and the European Convention on Human Rights oversea and steer the direction of equality, diversity and inclusion at HHCT advise and report to Trust Board and Executive Team, via the Quality and Safety Committee, on matters relating to Equality Diversity and Inclusion promote an inclusive culture at HHCT where individual differences are understood, valued and celebrated 2.0 Duties Own, promote and embed an equality, diversity and inclusion strategy for HHCT, and monitor thereafter. Provide practical guidance on how equality, diversity and inclusion relate to HHCT s mission to provide fair access for all; in an environment where human rights, dignity and individuality is respected and promoted. Ensure inclusion and diversity is at the heart of all HHCT s strategies. Monitor and evaluate the impact of internal (HHCT) HR practices on EDI. Page 7 of 13
Work with partner organisations and external stakeholders on equality, diversity and inclusion issues. Support the building of evidence base to inform HHCT s activities. 3.0 Reporting Responsibilities The Committee will: Report to the Quality and Safety Committee on activities and future plans Brief the Workforce Committee on actions relating to the Trust s workforce Undertake any other tasks delegated by the Quality and Safety Committee, as well as the Trust Board and Executive Team, within the overall purpose of the Committee Support the work of the Remuneration Committee, Charitable Funds Committee and Audit and Risk Committee Support the work of staff-led sub-groups, which shall report directly to the EDI Committee 4.0 Authority The Committee has been authorised by the Trust Board and Hospital Management Committee to investigate any activity within the Terms of Reference. It may seek information if it requires from any employee and all employees are to be directed to cooperate with any request made by the group. The group can seek external advice from any source necessary taking into consideration financial constraints and guidelines of the trust. The group is authorised to create sub groups, working groups and workshops when necessary to fulfil its responsibilities within the Terms of Reference. 5.0 Membership and Attendance Actual membership is under review. The membership of the committee will exemplify HHCT s approach to equality, diversity and inclusion. Appointments will be made such that the Committee is as diverse as possible, and the appointment process will be accessible and inclusive. Page 8 of 13
As vacancies arise, available skills will be reviewed, and any requirements in relation to the posts to be filled will be identified. The Committee has joint and collective responsibility for agreeing all decisions. Decisions shall be reached by consensus where possible, and where there is not a unanimous agreement a vote shall be taken and result recorded. The Ordinary mode of decision shall be a show of hands or, if demanded, by a ballot of those present. Each Officer shall have one vote. In the case of an equality of votes, either upon a show of hands or upon a ballot, the Chair shall have a second or casting vote. In the event of an urgent decision being required between meetings on any matter within the Terms of Reference of the Committee, the Chair may take Chairs action. The action will be reported to the next meeting and recorded in the minutes/notes. The normal term of office for a Member of the Committee shall be two years but this can be extended with agreement of the Trust Board but shall be no longer than two terms. 6.0 Meeting frequency Meetings will be held monthly until December 2016, at which point the frequency will be reviewed. Meetings will last approximately 2 hours. Members are asked to attend at least 75% of the meetings. Attendance will be monitored, and members may be asked to leave the Committee if it falls below acceptable levels. The draft agenda and supporting material where practically possible will be issued to the Committee members at least 7 days prior to the meeting. To add to or amend the agenda all replies should be in writing and received by the Secretary at least 4 days prior to the meeting. Papers may be tabled on the day in exceptional circumstances. 7.0 Reporting guidelines Full minutes, exception reports and the action log will be circulated to the Quality and Safety and Workforce Committees, members of the EDI Committee, and members of staffled sub-groups. Page 9 of 13
8.0 Policies, procedures and strategies The Committee is responsible for the implementation, maintenance and monitoring of the following: Equality, Diversity and Inclusion Strategy Equality, Diversity and Inclusion Action Plan Equality and Inclusion Policy Equality Delivery System (EDS2) Workforce Race Equality Standard (WRES) Accessible Information Standard Equality Impact Assessments 9.0 Monitoring Compliance and Effectiveness In order to support the continual improvement of EDI within HHCT it is required to annually: Carry out an internal self-assessment of the outcomes and effectiveness of the group, taking into consideration the completion of all actions set and deadlines met. Review of Terms of Reference for the Committee annually to reaffirm the purpose and objective. Report assurance to the Trust Board and Executive team, via the Quality and Safety and Workforce Committees, on those matters covered by these Terms of Reference. 10.0 Key Indicators NHS England EDS2 WRES CCG contract Frances Report Outcomes NHS Operating Framework NHSLA Risk Management Standards Care Quality Regulations and Outcomes Page 10 of 13
Appendix 3: EDS2 Steps for Implementation There are nine steps to consider when implementing EDS2. The steps are inter-related and generally sequential. All the steps are important but good governance linked to mainstream business, inclusive engagement with a wide range of stakeholders, and the use of a range of evidence and insight provide solid foundations for successful EDS2 implementation. In summary, the steps are: 1. Confirm governance arrangements and leadership commitment 2. Identify local stakeholders 3. Assemble evidence 4. Agree roles with the local authority 5. Analyse performance 6. Agree grades 7. Prepare equality objectives and more immediate plans 8. Integrate equality work into mainstream business planning 9. Publish grades, equality objectives and plans A selective but balanced approach to which services are assessed and graded using EDS2 is recommended. A proportionate mix of services where equality-related progress has been made, and services where equality-related problems persist, will give an accurate picture of how well we are performing. We will assess and grade our performance across all EDS2 s outcomes, except for when there is a compelling reason for being selective. We might be selective in the choice of services we review and, where there is a strong local need to do so. We might also look at particular aspects of protected characteristics. Page 11 of 13
The short animation video below explains simply what EDS2 is and how it should be implemented. Further information about EDS2 can be found here. Page 12 of 13
Appendix 4: Workforce Race Equality Standard (WRES) Workforce Race Equality Standard (WRES): tackling race inequality across the workforce In 2014, the NHS Equality and Diversity Council announced that it had agreed action to ensure employees from black and ethnic minority (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace. This followed reports that highlighted disparities in the number of BME people in senior leadership positions across the NHS, as well as lower levels of wellbeing amongst the BME population. The Council pledged its commitment to implement measures to improve equality across the NHS, one of which is the Workforce Race Equality Standard (WRES), which requires organisations to demonstrate progress against a number of indicators of workforce equality, including a specific indicator to address the low levels of BME Board representation. The WRES Standard, alongside EDS2, is included in the 2015/16 Standard NHS Contract. The regulators, the Care Quality Commission (CQC), National Trust Development Agency (NDTA) and Monitor, use both standards to help assess whether NHS organisations are well-led. The Standards are applicable to providers, and extended to clinical commissioning groups through the annual CCG assurance process. Further information about WRES can be found here. Page 13 of 13