equality & human rights strategy 2016 - 2019 · pennine acute hospitals nhs trust equality...

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Equality & Human Rights Strategy 2016 - 2019

Document Number: EDH041

Version: Version 3

Authorised by: Trust Board

Date authorised: 31st March 2016

Next review date: 31st March 2018

Document Author: Naheed Nazir – Head of Equality

This document can be provided in alternative formats

Fairness

Respect

Equality

Dignity

Autonomy

Better Health Outcomes for ALL

Improved Patient & Carer

Access and Experience

Empowered, Engaged and included staff

Inclusive Leadership at

ALL Levels

http://nm-ashanti:86/dms/default.aspx

Pennine Acute Hospitals NHS Trust Equality & Human Rights Strategy 2016 – 2019: Ref No. EDH041 Version 3

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Contents Page

1. Our Strategy at a Glance 3

2. Scope of the Strategy 4

3. Vision of the Strategy 4

4. Aims of the Strategy 5

5. Our Trust’s Equality Pledges 5

6. How we will drive and enable change 5

7. How we will measure progress 9

8. Our projected timescales 9

9. How we will engage our staff & patients 9

10. How we will communicate our strategy & progress 10

11. How you can share your views 10

12. Appendices 11

Appendix 1 – Protected Characteristics 11

Appendix 2 – Public Sector Equality Duties 12

Appendix 3 – Workforce Race Equality Standard 14

Appendix 4 – Duty to Make Reasonable Adjustments 16

Appendix 5 – Accessible Information Standard 18

Appendix 6 – Human Rights Information 19

Appendix 7 – Action Plan 20



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1. Our Strategy at a glance

Engaging protected groups to identify health needs

and aspirations.

Showing 'due regard'; undertaking Equality Analysis and Human Rights screening on decisions, priorities,

policies and strategies.

Involving protected groups in service design and redesign.

Building in Equality & Inclusion criteria to all

contracts, for example EDS Performance tool.

Patient Centred Procurement and Contracting; involving

protected groups in Tender Process.

Ensuring the Trust monitors access to services by

protected groups. Building in Equality returns to reviews.

Ensuring that Trust Staff have received training to enable them to embed Equality & Inclusion within

their day to day role.

Patient Centred Performance Management , for example

using the NHS Equality Delivery System..

Ensuring collaborative partnership working with local stakeholders, third sector and

communitiy groups..

Equality Objective 1

To ensure involvement of

patients in decisions about

their care and any

changes to the services

offered by the Trust.


To increase engagement

with staff and staff side

organisations, patient,

carers, local interest and

community groups and

Trust Members at a local

level.


To achieve a workforce

that is representative of

the communities we

serve.


To improve the

accessibility of

information for all

service users across all

sites.

Listening and Learning

Gaining and using Knowledge

Mainstreaming Equality and

Human Rights

Using the Equality Delivery System

(EDS2), Workforce Equality

Standards, and Accessible

Information Standard to drive

improvements

Equality and Human

Rights at the Heart of All

We Do at Pennine Acute

Hospitals NHS Trust



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2. Scope of the Strategy

Pennine Acute Hospitals NHS Trust has an obligation to provide equitable and

accessible services and advance equality of the people of North East sector of

Manchester and surrounding boroughs and its employees. With due regard to the

elimination of discrimination, the promotion of equality opportunity and the

fostering of good relations

between people who have a

protected characteristic (see

Appendix 1) and those who

do not in accordance with

the Public Sector Equality

Duty of the Equality Act

2010.

With this in mind the Trust

puts people at the heart of

the organisation and of the services we provide. We believe that all people have

the right to be respected, valued and empowered within an environment that is the

very best we can provide for each person on every occasion.

The Trust has given consideration to issues of equality and discrimination in the

development of this strategy and plans to do this before making any policy

decision that may impact on protected groups. This requirement is seen as an

integral and important part of the mechanisms for ensuring the aims of anti-

discrimination legislation in the Equality Act 2010.

The Trust’s strategic approach is that actions taken by the Trust e.g. delivering,

buying, redesigning health care must be generally applicable, but with a scale and

intensity that is proportionate to the possible level of disadvantage experienced by

different communities including those with different protected characteristics. The

Trust is also obliged to promote and protect people’s human rights in carrying out

its functions as set out in the Human Rights Act 1998 and the NHS Constitution

2012.

3. Vision of the Strategy

The Trust’s vision is to be 'A leading provider of joined up healthcare that will support every person who needs our services, whether in or out of hospital to achieve their fullest health potential.'

This strategy intends to enable the Trust in meeting this vision through ensuring services delivered by the Trust are tailored to meet people’s needs and are fully accessible and that our staff will be engaged and supported by fair employment and good work, that attracts, retains and develops the best talent from across society.

Patient care is at the centre of everything we do. We

work together to deliver a high quality service to

provide the best possible outcome for our patients.

Accountability, honesty and integrity are key to our

success both individually and across the Trust.

Treating everyone with respect and promoting good

working relationships will support individuals in

reaching their full potential.



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4. Aims of the strategy

1. To support the Trust in embedding equality of opportunity, including the Equality Act 2010 compliance, not only for the Trust but our customers and our subcontractors too.

2. To support the Trust and the wider NHS in the Greater Manchester area in addressing health inequalities, including complying with relevant legal duties.

3. To support the Trust and the wider health and social care economy in creating services and care pathways that eliminate wide variations in health outcomes, ensuring fairness and equity that are inclusive and based upon the values on the NHS Constitution ensuring we have a system where everyone counts.

5. Our Trust’s Equality Pledges

In delivering this strategy all Trust staff will work to the following principles:

1. We will ensure the values of the NHS Constitution influence all decisions taken by the Trust. Our Values guide every action we take. They determine how we work and the promise we make to our patients, their families, the public and each other as colleagues. WE ARE: Quality Driven, Responsible, Compassionate

2. We will work with all NHS colleagues, service users and key equality stakeholders to enable the mainstreaming of equality and human rights into all core business where possible ensuring the best use of resources in delivering this strategy

3. We will undertake annual EDS2 grading and demonstrate improvement against all outcomes applicable to the Trust

4. We will work to meet the Public Sector Equality Duties as set out in the Equality Act 2010 and will report our equality information annually

5. We will promote and protect people’s rights in decision making ensuring that decisions are legal, proportionate and have shown due regard to the Public Sector Equality Duty

6. How we will drive and enable change

Public Sector

Equality Duties

(PSED)

Duty to Make

Reasonable Adjustment

Equality Delivery System (EDS2)

Trust Equality

Objectives

Workforce Equality

Standards

e.g. WRES

Accessible Information

Standard

Human Rights duty to Promote and Protect



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The delivery mechanisms for the strategy include:

6.1 Equality Delivery System for NHS

The Equality Delivery System (EDS2) is a toolkit that can help the Trust to

demonstrate how they are understanding and tackling inequalities in service

delivery for people with different protected characteristics and how they are

providing better working environments for staff. The grading of the Trust will be

carried out by key stakeholders gathered from local communities, Community,

Voluntary and Faith Groups, Health Watch representative and our employees on

an annual basis the outcomes of the grading will enable the Trust to refine and

further develop its Equality Objectives set out below.

6.2 Trust Equality Objectives

1. To promote involvement of patients in decisions about their care and any changes to the services offered by the Trust

2. To increase engagement with staff and staff side organisations, patient, carers, local interest and community groups and Trust Members at a local level

3. To work towards having a workforce that reflects the communities we serve

4. To improve the accessibility of information for all service users accessing services across all sites

These equality objectives have been drafted following previous Equality Delivery

System (EDS2) grading undertaken by the Trust and through engagement with

key equality stakeholders. These objectives will be reviewed annually after each

round of EDS2 grading and revised accordingly to ensure they remain relevant to

the people we serve and those who are employed within the Trust.

6.3 Equality Committee

The role of the Committee is to ensure the principles of equality and human rights

are embedded into the mainstream activities of all Trust functions and is the

main vehicle for driving change through the organisation. This group is

responsible for promoting, encouraging and ultimately delivering greater equality,

diversity and inclusion for the benefit of the Trust service users and staff. The

approach of the Equality, Diversity & Inclusion Committee is based on the

following principles:

Everyone has the right to be treated fairly and with dignity and respect

Achieving equality requires awareness, understanding, commitment and positive action from very individual employee in the Trust at every level and across all disciplines

Diversity must be recognised and valued.



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6.4 Public Sector Duties

The first public sector duty

was introduced by the Race

Relations (Amendment) Act

2000 – this was the Race

Equality Duty. Before the

implementation of this duty

legislation was already in

place to protect individuals

from discrimination;

however, it was the

responsibility of the

individual to bring a case

forward and they could only

do so after the alleged

discrimination had occurred.

The introduction of the Public Sector Equality Duty brought about a change in the

way that equalities law should be viewed and implemented. It shifted the

responsibility away from individuals to have to bring a case and instead placed the

onus on public bodies such as the NHS to promote equality and diversity when

carrying out all of its functions, either as a service provider or employer, (see

Appendix 2).

6.5 Workforce Equality Standards

The Trust currently is mandated to work on the NHS England Workforce Race

Equality Standard ( see below), however is currently developing Workforce

Equality Standards in protected characteristics of Disability, Sexual Orientation

and Gender Reassignment (LGBT)

6.5.1 Workforce Race Equality Standard (WRES)

In April 2015 NHS England introduced the Workforce Race Equality Standard

(WRES). The standard consists of a 9 indicators and requires NHS organisations

to close the gap between the BME and white staff experience for those indicators.

The WRES directly supports the Equality Delivery System (EDS2) goals 3 and 4:

representative workforce and inclusive leadership including the Board and

indirectly supports EDS2 Goals 1 and 2: Better Health Outcomes and Improved

patient access and experience. Pennine Acute is already working towards

implementing the EDS2.

The Trust successfully completed the baseline data requirements and completed

their submission. This is located on the Trust website. The Trust will be forming a

working group who will have the responsibility to implement, monitor and review

the action plan, (see Appendix 3).

Equality Act 2010 Protected Characteristics



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6.6 Duty to Make Reasonable Adjustments

Pennine Acute Hospitals NHS Trust must take positive steps to remove the

barriers people face because of their disability; this includes patients, carers and

employees. This is to ensure they receive the same services, as far as this is

possible, as someone who's not disabled. The Equality Act 2010 calls this the

duty to make reasonable adjustments, (see Appendix 4).

6.7 Accessible Information Standard

The ‘Accessible Information Standard’ is a mandatory requirement that outlines a

specific, consistent approach to identifying, recording, flagging, sharing and

meeting the information and communication support needs of patients, service

users, carers and parents, where those needs relate to a disability, impairment or

sensory loss.

The Standard applies to services provided by Pennine Acute Hospitals NHS Trust

and to support effective implementation the Trust has in place an implementation

plan. The Trust believes that successful implementation of this standard across all

services will lead to improved outcomes and experiences, and the provision of

safer and more personalised care and services to those individuals who come

within the Standard’s scope, (see Appendix 5).

6.8 Human Rights

The Trust believes that human rights and patient centred care as core concepts

have become inseparable. Our own mission statement is evidence of our

commitment to ensuring that the rights and needs of each individual are met whilst

providing the best health care possible. The Trust is committed to operating and

human rights based approach ensuring our staff understand their roles in

promoting and protecting people’s rights and applying the basic human rights

principles of ensuring fairness, respect, equality, dignity and autonomy throughout

interaction with colleagues and service users in our day-to-day working lives.



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7. How we will measure progress

The Trust’s Executive Director of Workforce and Organisational Development

supported by the Head of Equality, Diversity & Inclusion will lead on driving

forward the strategic priorities and deliverables set out in this strategy. Progress

against the delivery of the strategy over the three years will be reported on a

quarterly basis through Equality Committee and any risks to the delivery of this

strategy will be reported via the Trust’s Risk register quarterly.

8. Our projected timescales

The Equality and Human Rights Strategy 2016 – 2019 has a life time of three

years with timescales allocated to each action and deliverable as set out in the

action plan, (see Appendix 7).

9. How we will engage our staff & patients

Pennine Acute Hospitals NHS Trust recognises the importance of consulting and

involving staff and service users in all aspects of the planning, development and

delivery of its responsibilities for equality. As consultation and involvement

become increasingly important in delivering patient centred and, ultimately, patient

led care, the Trust has produced a Patient and Public Involvement Best Practice

and Guidance document, which is available on the Trust’s website.

Consultation may take a range of forms such as patient and staff surveys, open

and/or focus group meetings, public scrutiny and written documents. It is generally

recognised that the process of consulting and involving service users creates a

culture of openness, transparency and accountability. This is extremely important

in ensuring that the on-going development of the Strategy and Action Plan takes

into account the changing needs of services users and staff. It also ensures that

the Strategy and Action Plan remains a living and breathing document with the

impetus on developing and striving forward with its aims and objectives.

Equality Committee Meetings

Monthly updates on Trust EDHR Strategy progress provided.

Trust EDS2 implementation plan progress quarterly.

EDS2 Grading outcomes reported annually.

Progress on WRES and Accessible Information Standard (AIS) reported quarterly.

Quality & HR/OD and Patient Experience Committees

Quarterly Assurance reports on Trust compliance provided.

Trust EDS2 implementation plan progress quarterly. Progress on WRES and AIS quarterly.

Trust Board

Quarterly Assurance reports on Trust compliance provided.

Annual Equality & Human Rights Report Provided and published by 31st January annually.

Reporting to the Public

31st

January

annually



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10. How we will communicate our strategy & progress

This revised strategy has been developed following the consultation with

Community, Voluntary and Faith Groups, Health Watch across the patch, the

Equality Committee and employees across all sites and various roles, for example

nurses, healthcare assistants, porters, consultants, admin assistants and

directors.

We will share this strategy with local communities through publishing it on our

website, providing copies to local community, voluntary and faith groups and local

Healthwatch Partnership Forum.

The strategy will be communicated with staff through the Mandatory and Induction

Training programme, Monday Message, Weekly Bulletin and the Intranet.

Progress against the strategy deliverables will be communicated to all key

stakeholders through local contractual meetings and all internal communication

channels including Equality Staff Networks.

Quarterly reports will be taken before internal committees and groups (see How we will measure progress section).

11. How you can share your views

If anyone would like to leave any comments of be involved in any part of the

delivery of the Strategy they can either contact the Equality Team via:

Telephone: 0161 604 5893 / 5891

Email: [email protected]


mailto:[email protected]


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Appendix 1 – Protected Characteristics

The Public Sector Equality Duty 2010 protected characteristics

1 Age By being of a particular age / within a range of ages

2 Disability A physical or mental impairment, sensory impairment

or leading disability which has a substantial and long

term adverse effect on day to day activities

3 Gender (sex) being a man or a woman, can include people who are

gender neutral and intersex

4 Gender

Reassignment

Transsexual people who propose to; are doing or

have undergone a process of having their sex

reassigned

5 Pregnancy and

maternity

If a woman is treated unfavourably because of her

pregnancy, pregnancy related illness or related to

maternity leave

6 Race Includes colour, nationality, ethnic origins and national

origins

7 Religion or belief

The full diversity of religious and belief affiliations in

the United Kingdom.

8 Sexual orientation

A person’s sexual preference towards people of the

same sex, opposite sex or both

9 Marriage and Civil

Partnership

This is relevant in relation to employment and

vocational training; the TRUST will ensure that this

protected group is considered in relation to

employment of staff and their training.



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Appendix 2 - Public Sector Equality Duties

The aims of the public sector duties are to make equality central to the way public bodies

work and to put it at the heart of policymaking, service delivery, and employment practice.

The legislation covering the Public Sector Duties has two main categories, these are the

general duties – which all public bodies have to abide by; and specific duties – which only

listed organisations, have to follow.

Some of the general duties include:

To Eliminate unlawful discrimination, harassment and victimisation

To promote equality of opportunity

To promote good relations between diverse groups of people

Some of the specific duties include:

Carrying out equality impact assessments

Consultation with the different groups and monitoring and publishing results

Provide an action plan to ensure that the requirements of the strategy are implemented.

In meeting out duties under the equality act we will deliver against the three aims of

the General Duty as set out below:

Aim 1: Eliminate unlawful discrimination, harassment and victimisation

Develop a Governance structure for Equality, Diversity and Human Rights

Ensure all staff undertake equality and diversity training at a level pertinent to

supporting them to carry out their role effectively

Equal opportunity policies are in place and reviewed in accordance with each

organisations policy guidance and amended as new legislation and guidance

requires

Human Resources (HR) recruitment policies (and exit interviews) are fair and

transparent.

Staff record any ‘Serious Untoward Incidents’ relating to the identified equality

strands

Customer Care Monitoring based on complaints, comments, compliments and

concerns is carried out

Organisations carry out access audits to ensure services are accessible.

Aim 2: Advance equality of opportunity between different groups

The Trust has in place and Equality Analysis and Impact Assessment Toolkit

The commissioning process includes the need to undertake Equality Impact

Assessments



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The Trust has an Engagement Toolkit /Strategy which aims to ensure that people of

protected groups are also engaged effectively

Human Resource Policies promote equality of opportunity for all staff at all levels

The Trust:

Promoting Staff Side activities

Work with Partner agencies form public and voluntary sector

Work with the Job Centre Plus e.g. Two Ticks Employer award for have

accessible employment for people with Disabilities.

Ensuring that reasonable adjustments are promoted and adhered to

Have in place Language Support Services

Aim 3: Foster good relations between different groups

All organisations carry out:

Engagement with the workforce, partners and statutory partners

Engagement with service users and carers

To assist in the implementation of the Strategy, the following key actions will be taken:

Publication of the Strategy on the Trust’s Internet pages.

An annual report on the Equality Strategy/Action Plan and impact assessments presented in the public section of the Trust Board reports.

Ongoing review of Equality and Diversity training to reflect changes in legislation and remains an integral part of mandatory staff training and development.

A commitment to meet the statutory duties is included in the job ‘statement’ in all new job descriptions.



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Appendix 3 – Workforce Race Equality Standard

Table 1 The Workforce Race Equality Standard indicators

Workforce indicators

For each of these four workforce indicators, the Standard compares the metrics for White

and BME staff.

1. Percentage of BME staff in Bands 8-9, VSM (including executive Board members

and senior medical staff) compared with the percentage of BME staff in the overall

workforce

2. Relative likelihood of BME staff being appointed from shortlisting compared to that of

White staff being appointed from shortlisting across all posts.

3. Relative likelihood of BME staff entering the formal disciplinary process, compared

to that of White staff entering the formal disciplinary process, as measured by entry

into a formal disciplinary investigation

Note. This indicator will be based on data from a two year rolling average of the

current year and the previous year.

4. Relative likelihood of BME staff accessing non mandatory training and CPD as

compared to White staff

National NHS Staff Survey findings

For each of these four staff survey indicators, the Standard compares the metrics for the

responses for White and BME staff for each survey question

5. KF 18. Percentage of staff experiencing harassment, bullying or abuse from

patients, relatives or the public in last 12 months

6. KF 19. Percentage of staff experiencing harassment, bullying or abuse from staff in

last 12 months

7. KF 27. Percentage believing that trust provides equal opportunities for career

progression or promotion

8. Q23. In the last 12 months have you personally experienced discrimination at work

from any of the following?

b) Manager/team leader or other colleagues

Boards. Does the Board meet the requirement on Board membership in 9

9. Boards are expected to be broadly representative of the population they serve.



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Calendar milestones for

meeting the Standard

Activity

April 1st 2015 Baseline data for comparison with April 2016

July 1st 2015 Publication of 1st April 2015 data including identification of

any essential shortcomings

April 2015 – March 2016 Work to start to address any data shortcomings and to

understand and address shortfalls identified by the WRES

indicators

April 2016 Baseline data for comparison with April 2015 should be

completed including steps underway to address key

shortcomings in data, or significant gaps between the

treatment and experience of white and BME staff.

1st May 2016 Baseline data to March 31st 2016 should be published to

Commissioner (for providers), on Trust web site and shared

with Board and staff



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Appendix 4 – The Duty to Make Reasonable Adjustments

Pennine Acute Hospitals NHS Trust must take positive steps to remove the barriers people

face because of their disability; this includes patients, carers and employees. This is to

ensure they receive the same services, as far as this is possible, as someone who's not

disabled. The Equality Act 2010 calls this the duty to make reasonable adjustments.

What’s meant by reasonable?

Adjustments only have to be made if it’s reasonable to do so and what is classed as a reasonable thing to ask for depends on things like:

A persons disability

how practicable the changes are

if the changes asked for would overcome the disadvantage individuals and other disabled people experience

the size of the organisation

how much money and resources are available

the cost of making the changes

if any changes have already been made.

What do people or organisations have to do?

There are three different things people or organisations may have to do make it easier for you to access or do something.

Change the way things are done

Some people or organisations may have a certain way of doing things which makes it more difficult for disabled people to access or do something. This could be a formal or informal policy, a rule or a practice. It could also be a one-off decision. The Equality Act calls this a provision, criterion or practice. The organisation should change these things if they are a barrier for disabled people, unless it’s unreasonable to do so.

Example:

An NHS Trust has a policy of only allowing staff to park in allocated staff car parks. A member of staff has a mobility impairment which means they need to be able to park close to where their work area is. This isn’t always possible as the allocated car parks are situated on one side only of the Trust grounds. Allowing you to park in designated parking spaces on all of the Trust grounds is likely to be a reasonable adjustment to their parking policy so that disabled staff can easily access work.

Change a physical feature

Sometimes a physical feature of a building or other premises may make it more difficult for disabled people to access or use it. Here are examples of physical features which it might be possible to change:

steps and stairs

passageways and paths

entrances and exits

internal and external doors

toilets



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signs

lighting and ventilation

the size of premises.

The kind of adjustments which could be made includes removing, changing or providing a way of avoiding the physical feature, where it’s reasonable to do so. Here are examples of reasonable adjustments:

providing ramps and stairway lifts

making doorways wider

installing automatic doors

providing more lighting and clearer signs.

Provide extra aids or services

Sometimes you may need particular aids or equipment to help you access or do something. Or a disabled person may need additional services. The Equality Act calls this auxiliary aids and services. Here are examples of auxiliary aids and services which could be provided to help you:

a portable induction loop for people with hearing aids

BSL interpreters

providing information in alternative formats, such as Braille or audio CD’s

extra staff assistance.

When do people have to do these things?

The Equality Act says there's a duty to make reasonable adjustments if disabled people are placed at a substantial disadvantage because of their disability compared to non-disabled people or people who don't share that disability. Substantial means more than minor or trivial.

Example:

A Deaf applicant is being interviewed at the Trust for a new post. Their first language is BSL and need an interpreter to communicate with the interview panel as they don't know BSL. Their disability places them at a substantial disadvantage compared to someone who's not deaf and who can communicate in English. The Interview Panel should therefore use a BSL interpreter when interviewing the job applicant.



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Appendix 5 – Accessible Information Standard

The aim of the Accessible Information Standard is to establish a framework and set a clear direction such that patients and service users (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss receive:

‘Accessible information’ (‘information which is able to be read or received and understood by the individual or group for which it is intended’); and

‘Communication support’ (‘support which is needed to enable effective, accurate dialogue between a professional and a service user to take place’);

Such that they are not put “at a substantial disadvantage…in comparison with persons who are not disabled” when accessing NHS or adult social services. This includes accessible information and communication support to enable individuals to:

Make decisions about their health and wellbeing, and about their care and treatment;

Self-manage conditions;

Access services appropriately and independently; and

Make choices about treatments and procedures including the provision or withholding of consent.

Note that guidance produced by the Equality and Human Rights Commission (EHRC) states that, “Anything which is more than minor or trivial is a substantial disadvantage.”

Task Date

Implementation date: organisations MAY begin to implement the standard.

Upon publication of the ISN – published Aug 2015

organisations MUST have begun to prepare for implementation of the Standard including developing and commencing rollout of a local implementation plan

Sept 2015

Organisations MUST identify and record information and communication needs when service users first interact or register with their service

By 1st

April 2016

Organisations MUST identify and record information and communication needs as part of on-going/routine interaction with the service by existing service users

From 1st

April 2016

Date of full conformance: full implantation of the Standard is required

By 31st

July 2016



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Appendix 6 – Human Rights

The Human Rights Act (HRA) 1998 came into force in October 2000. In light of this

legislation, all public authorities had to take into consideration the relevant articles of the

HRA in all its decisions and policies implemented whilst promoting and protecting the

rights of employees and the wider community.

The Trust is committed to ensuring that human rights are an integral part of the equality

impact assessment process, which helps us to address hidden discrimination or

inequalities. In undertaking our duties as the purse holder for the local health services we

will follow the PANEL principles. In practice this means:-

Participation

Everyone has the right to participate in decisions which affect their human rights. Participation must be active, free, meaningful and give attention to issues of accessibility, including access to information in a form and a language which can be understood.

Accountability

Accountability requires effective monitoring of human rights standards as well as effective remedies for human rights breaches. For accountability to be effective there must be appropriate laws, policies, institutions, administrative procedures and mechanisms of redress in order to secure human rights.

Non-discrimination and equality

A human rights based approach means that all forms of discrimination in the realisation of rights must be prohibited, prevented and eliminated. It also requires the prioritisation of those in the most marginalised situations who face the biggest barriers to realising their rights.

Empowerment of rights holders

A human rights based approach means that individuals and communities should know their rights. It also means that they should be fully supported to participate in the development of policy and practices which affect their lives and to claim rights where necessary.

Legality of rights

A human rights based approach requires the recognition of rights as legally enforceable entitlements and is linked in to national and international human rights law.



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Appendix 7 – Action Plan

Action Plan 2016-2019

Equality Objective Action Outcome Lead Timescale

To promote involvement

of patients in decisions

about their care and any

changes to the services

offered by the Trust

1. To review the Equality Analysis Process to ensure effective engagement is being included in the process across all protected groups

2. To identify areas where there are gaps and issues

3. To ensure this requirement is included in the Tier 1 and Tier 2 training so that staff understand their roles

4. Design and deliver additional training for staff in the collection of equality monitoring information where required.

5. Review of equality monitoring data for engagement and involvement activity to get a clearer picture.

6. Capture case studies of patient experience of involvement in decision making to ensure it is effective for people across all protected groups

1. Patients/Carers/Advocates report positive experience of being involved in decision making about their carer

2. Staff report positive experiences of involving people in decisions about care and changes to services

3. Friends and Family Tests show positive outcomes

4. Complaints about involvement reduce

5. Trust receives positive grading in EDS2

Communications &

Engagement

Patient Experience

Lead

L&OD & Equality Lead

Reported bi-monthly

at Patient

experience

Committee

Equality, committee

Quarterly Board

update

Bi-monthly reporting

to Quality Leads

meeting

To be reviewed on

annual basis


Pennine Acute Hospitals NHS Trust Equality & Human Rights Strategy 2016 – 2019:Ref No. EDH041 Version 3

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To increase

engagement with staff

and staff side

organisations, patient,

carers, local interest

and community groups

and Trust Members at a

local level

1. To have staff side representation on the Trust Equality, Diversity and Inclusion Committee

2. To include people with protected groups in engagement activities.

3. To monitor engagement with community groups to ensure full range of protected characteristic groups are involved

4. To include representatives of local community groups on the Equality, Diversity and Inclusion Committee

5. To ensure effective representation on the Health Watch Partnership Group

6. To involve representatives of staff, staff side, local interest groups and communities in the EDS2 grading annually

1. Trust can evidence engagement of

people across all protected groups in

EDS2 grading

2. Trust can evidence outcomes of

engagement activity and demonstrate

involvement of people with different

protected characteristics

3. Trust receives positive grading at EDS2

grading annually

Partnership Lead Comms and

Engagement Lead

Equality Lead

Reported bi-monthly

at Equality,

committee

Quarterly Board

update

To be reviewed on

annual basis

To work towards having

a workforce that reflects

the communities we

serve

1. Implement the Workforce Race Equality Standard (WRES) action plan

2. Review workforce profile and identify gaps and trends in under-representation and develop an action plan identifying actions to improve diversity

3. Work with the BME, LGBT and Disability Staff Networks to identify positive actions to improve diversity of these three groups across all levels of the Trust

4. Work with local education providers including Further and Higher Education Centres to consider issues re skill gaps in under-represented groups

5. Consider mentoring opportunities for people from under-represented groups

6. Consider sponsoring staff from under-represented groups to attend leadership development programmes e.g. NW Leadership Academy programme for BME Staff

1. Trust has an understanding of gaps and

under-represented group in current

workforce

2. Improved diversity in the workforce

3. Improved quality of service to diverse

population where workforce represents the

population being served

4. Improve job satisfaction of staff

Workforce and OD Lead Equality Lead

Learning & OD

Reported bi-monthly

at Workforce and

OD Leadership

Board & Equality

committee

Quarterly Board

update

To be reviewed on

annual basis


Pennine Acute Hospitals NHS Trust Equality & Human Rights Strategy 2016 – 2019:Ref No. EDH041 Version 3

of 22



To improve the

accessibility of

information for all

service users accessing

services across all sites

1. Implement the Accessible Information

Standard Action Plan

2. Review all patient information leaflets to

ensure they are accessible and work with

local communities to develop new leaflets

work with local communities such as the

d/Deaf, visually impaired and people with

Learning Disability to ensure information

and services are accessible

3. Review Trust Website for accessibility and

revise where gaps are found, work with

local communities such as the d/Deaf,

visually impaired and people with Learning

Disability to ensure information and

services are accessible

4. Undertake access audits across all sites,

wards and departments , working with

patient experts/mystery shoppers to

identify best practice and areas for

development

1. Services and Information are fully accessible for Disabled people and those with community languages or do not have English as a first language

2. Trust meets Information Standard requirements

3. Trust website is fully accessible

4. Trust receives positive CQC Inspection

ratings

5. Trust receives positive EDS2 Grading for Goal 2 outcome 2.1

IM&T

Equality Lead

Reported bi-monthly

at Equality,

committee

Quarterly Board

update

To be reviewed on

annual basis

To undertake annual Equality Delivery System (EDS2) Grading

See separate EDS2 Implementation Plan

EDS2 PlanPAT

To implement mandated and voluntary Workforce Equality Standards

See separate Workforce Race Equality Standard (WRES) Action plan See separate Workforce LGBT Equality Standard Action Plan (Draft) See separate Workforce Disability Equality Standard Action Plan (Draft) WRES action plan

2015.docx

To put in place actions to ensure the Trust is meeting the mandatory Accessible Information Standard

See separate action plan

AIS PLAN V1.docx


equality & human rights strategy 2016 - 2019 · pennine acute hospitals nhs trust equality...

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