Contents Foreword & Introduction, page 3. Due regard and equality analysis reports Equality Delivery Systems 2 (EDS2), page 4. Local Approach to EDS 2 How did we do? Equality Objective Plan 2016/19, page 6. Monitoring Equality Performance with key NHS providers, page 6 Equality and the Workforce, page 8 EDS 2 and the workforce Governance, page 8. Conclusion, page 8 Appendices, page 9 to page 31 Appendix 1 - CCG EDS 2 grades, page 9 Appendix 2 -Equality objective Plan 2012/2020, page 12 to 26 Appendix 3 - EDS 2 Provider performance, page 27 to 28 Appendix 4 - E&D Workforce Plan, page 29 to 31
1.5 Local health information and communications reach communities Achieving Developing Improved patient access and experience 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds Developing Developing 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care Developing Developing 2.3 People report positive experiences of the NHS Developing Developing 2.4 People’s complaints about services are handled respectfully and efficiently Developing Developing A and supported workforce 3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels Achieving Developing 3.2 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 Achieving Developing 3.3 Training and development opportunities are taken up and positively evaluated by all staff Developing Developing 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source Developing Developing 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives Developing Developing 3.6 Staff report positive experiences of their membership of the workforce Developing Developing Inclusive leadership 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations Achieving Developing 4.2 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 Achieving Developing 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination Developing Developing
APPENDIX 2 NHS Halton CCG Equality Objective Plan 2017-2020 The CCGs current equality objectives are:- To make fair and transparent commissioning decisions; To improve access and outcomes for patients and communities who experience disadvantage To improve the equality performance of our providers through robust procurement and monitoring practice To empower and engage our workforce Protected Characteristic Key Issue and Barrier Identified Action and Activity Responsible Officer Date EDS Outcome PSED CCG Equality Objective Race Language and cultural barriers Consider implementation of the new NHS England Translation and Interpretation (T&I) Framework for primary care when it is launched in 2016/17 Head of Primary care Awaiting launch 1.1, 1.2,1.3, 1.4, 1.5, 2.1, 2.2, 2.3, 2.4 Eliminate Discrimination Advance Equality Of Opportunity Equality Objectives 1,2,3 Develop a local T&I Policy and awareness raising programme for the CCG and Primary Care (and cross-reference with the NHS England guidance when received). Senior Governance manager & Head of Primary Care & Engagement and Communication Manager March 2018 In progress
Identify relevant data that can support the CCG to measure T&I usage in Primary Care Senior Governance manager & head of Primary Care July 2018 In progress Ensure key secondary care providers continue to report on T&I usage as set out in the Quality Contract Schedule 2016/17 Chief Nurse Completed CCG to consider developing a Bilingual Volunteer project to provide non- clinical T&I support to the CCG and partners Senior Governance manager & Head of Governance March 2018 In Progress Race Lack of understanding of which services to access and inappropriate A&E attendance Work collaboratively with relevant community groups and health services to develop local communications to support appropriate access - including registration with GPs Senior Governance manager & Engagement and Communications Manager & Voluntary Sector Stakeholders March 2018 (In progress) 2.1, 1.1 Advance Equality of Opportunity
Equality Objectives 1,2 Ensure Specification for CCG funded Community Development (CD) BME related project reflects actions within the Equality Objective Plan and EDS2 exercise Intelligence barriers feeds into CCG Head of Children & Families, Adult Mental Health March 2017 Completed Race Lack of Cultural understanding within commissioning and primary and secondary care services Promote CD BME organisation’s offer and promote cultural competency training across CCGs, primary and secondary care Head of Children & Families, Adult Mental Health December 2017 Completed 1.1, 1.5, 2.1 Advance Equality Of Opportunity Foster Good Community Relations Equality Objectives 1, 2,3 Disability / age /older citizens and young people Lack of understanding of mental health resulting in Ensure issues identified in the EDS2 engagement, as addressed in the CCG’s Mental Health Strategy, are raised at the Merseyside Quality Surveillance Group (co-ordinated by Halton CCG’s Head of Quality and Chief Nurse ) Chief Nurse & Head of Children & Families, Adult Mental Health December 2016 Completed 2.1,1.2, 1.3, 1.4 Eliminate Discrimination Advance Equality Of
negative attitudes Opportunity Equality Objectives 1,2,3 Disability / age / frail elderly Lack of understanding of reasonable adjustments by health professionals across health services Implement Accessible Information Standard Duty to make Reasonable Adjustments Accessible information Standard is embedded across the CCG and promoted across GP Practices Senior Governance manager & Head of primary Care March 2018 In progress 1.1,1.2,1.3,2.1 Advance Equality of Opportunity Equality Objectives 1,2,3 Develop a local T&I policy and awareness raising programme for the CCG and Primary Care. (Future NHS England guidance will be cross referenced into the local policy and programme) Senior Governance manager & Engagement and Communications Manager & Head of Primary Care March 2018 Completed Develop comprehensive reasonable adjustment guidance to support improvements in standards in Primary, Community and Secondary Care and share with the Local Authority to consider for their services Senior Governance manager & Head of Corporate Services December 2016 Completed
Ensure Accessible Information Standard and the need to make reasonable adjustments is monitored with the providers via the Quality Contract Schedule Senior Governance Manager Chief Nurse Completed Develop and distribute Reasonable Adjustment Guidance Develop communication brief on the Standard to be issued to primary care (GPs) Senior Governance manager & Engagement and Communications Manager Completed Produce brief ‘Consider Reasonable Adjustments’ CQUIN proposal’ and address in Quality schedule Senior Governance manager Completed
Age - young people and working age older citizens Further explore potential for vulnerable Young People to face disadvantages Issue will be addressed in the Merseyside Quality Surveillance thematic work stream for mental health and Crisis Care (co-ordinated by Halton CCG’s Head of Quality and Chief Nurse ) Senior Governance Manager & Chief Nurse December 2016 Completed 1.1, 1.2, 1.4, 1.3 Advance Equality of Opportunity Equality Objectives 2,3 Age - older citizens Waiting times and timescales of referrals and appointments for frail elderly and older citizens living alone Address concerns raised by age organisations in the community specifically on inappropriate appointment times in Primary and Secondary Care (in conjunction with Halton CCG’s Head of Quality and Chief Nurse ) Head of commissioning & Chief Nurse December 2018 1.1,1.2,1.3, 1.4, 2.1, 2.3, Advance Equality of Opportunity Equality Objectives 2,3 Implement Accessible Information Standard into provider contracts and monitor Deputy Chief Nurse & Senior Governance Manager & Head of corporate services Completed
Age Access to primary care for vulnerable young people Lack of understanding regarding children and young people Work underway via review of children’s Mental Health Services Head of Children & Families, Adult Mental Health Completed 2.1, 1.4 Advance Equality of Opportunity Foster Good Community relations Equality Objectives 1,2,3 Ensure Serious Incidents Policy and activity consider PSED and needs associated with protected characteristics via the Quality Surveillance Group in conjunction with Halton CCG’s Head of Quality and Chief Nurse Senior Governance & Chief Nurse March 2018 Forward concerns on lack of understanding of legal highs by partners to Local Authority (Public Health) highlighting the need for an awareness raising campaign Chief Nurse December 2016 Completed
Transgender Lack of understanding of trans issues and variation in service standards Explore options to improve knowledge and understanding of the Transgender community across health services (issues raised are stored in EDS Engagement Excel spreadsheet) via the Quality Surveillance Group in conjunction with Halton CCG Continue to develop local responses to Trans needs across Primary Care and links with In Trust Merseyside Senior Governance Manager & Chief Nurse Head of Primary Care March 2018 On- going 1.1, 1.2, 1.3, 1.4, 2.1, 2.2, 2.3 Eliminate discrimination, Advance Equality of Opportunity Equality Objectives 1,2,3,4 Sexual Orientation & Transgender Poorer patient experience and lack of understanding of needs across health services Develop a proposal to support and improve awareness raising of LBGT issues across the CCG, primary care and secondary care to improve access and outcomes Please note barriers are listed in the EDS2 engagement document Senior Governance Manager & Communications and Engagement Manager & Chief Nurse & Head of Governance March 2018 In progress 1.1, 1.2, 1.4 Eliminate Discrimination Advance Equality of Opportunity Foster Good Community relations Equality Objectives 1,2,3,4
Pregnancy & Maternity Barriers will be identified via the maternity services review pre and post Equality Assessment process Barriers will identified via the maternity services review pre and post Equality Assessment process –in line with Improving Me timescales Co-ordinating CCG lead (Halton CCG) Programme Director – Maternity and Women’s Services March 2018 On going 1.1,2.1,1.21.3 Eliminate Discrimination Advance Equality of Opportunity Foster Good Community Relations Equality Objectives 1,2,3,4 All Protected Groups Human resources and workforce Develop an Equality Workforce Plan in conjunction with CSU HR Business Partners to be ratified and approved at CCG HR Committee CSU Business Partner Head of Corporate Services Completed 3.1,3.2,3.3,3.4,3.5,3.6 Eliminate Discrimination Advance Equality of Opportunity Foster Good Community relations
Equality Objective 4 Embed and implement the Workforce Race Equality Standard Head of Corporate Services April 2016 Completed All Protected Groups Ensure EDS2 approach and plans are embedded into the refreshed Communications and Engagement Plans & activity Communication and Engagement Manager & Head of Corporate Services November 2018 In progress Equality Objectives 1,2,3,4 All PSED 1.1,1.2,2.1,4.2 Ensure that Governing Body, and other key decision- making panels (including Individual Funding Requests) and programme leads receive the appropriate level of E&D training Senior Governance Manager & Head of Corporate Services March 2018 In Progress
3.6 Achieving Achieving Achieving Developing Achieving Developing Developing Inclusive leadership 4.1 Achieving Developing Achieving Developing Achieving Developing Developing 4.2 Achieving Developing Achieving Developing Developing Developing Developing 4.3 Achieving Developing Achieving Developing Achieving Developing Developing APPENDIX 4 Workforce E&D plan and progress report Task Activity Outcome EDS comparator Action plan Policy Proofing 2016-2018 Prioritise policies Identify policy against essential list Proportional input. Cover 3.4 All CCG HR Policies which have been ratified have now been equality impact assessed.
Owner – HRBP In Progress Annual review Establish best measure for review programme Performance of policies monitored against PSED 3.3 3.4 3.5 4.3 Equality impact assessments completed as policies produced/reviewed Owner – CCG Supported by HRBP See Monitoring as above. In Progress Staff surveys The CCG to consider rolling out staff survey including questions on E&D Understanding staff relationship with organisational culture to eliminate any institutional discrimination 3.4 3.6 4.3 CCG Staff survey drafted Owner – CCG Completed Positive Action Monitor performance against policies to establish base line Identify trends Establish conditions for positive action Challenge barriers if data/evidence identifies them Advance equality of opportunity. 3.2 3.5 3.1 3.3 3.5 4.1 4.3 HRBP is currently working with the Workforce Team to establish relevant monitoring systems for each of these key policies Awaiting Task and Finish Groups. Owner – HRBP In progress