Public Sector Equality Duty Report 2015 Pdf 1.1MB

PUBLIC SECTOR EQUALITY DUTY

ANNUAL REPORT 2015

Contents Page

Accessibility ...... 3 Section One ...... Error! Bookmark not defined. Executive Summary Section Two ...... Error! Bookmark not defined. Welcome Statement Section Three ...... 9 Introduction Section Four ...... 12 Governance Section Five ...... 13 Compliance with the Public Sector Equality Duty Section Six ...... 16 Manchester Demographics and Health Profile Section Seven ...... 19 EDHR in Commissioning – (evidence based approach to commissioning) Section Eight ...... 22 Decision Making (Equality Analysis) Section Nine ...... 23 Performance Monitoring of Providers Section Ten ...... 25 Workforce Section Eleven ...... 26 EDHR Objectives Section Twelve ...... 32 Connecting with our Communities Section Thirteen ...... 39 Next Steps Section Fourteen ...... 41 Appendix A – Decision Making (Equality Analysis) Appendix B – Performance Monitoring of Providers Appendix C – Workforce Data Appendix D – EDS 2 Report 2015

Accessibility Manchester Clinical Commissioning Groups (CCGs) support the NHS Accessible Information Standards and, therefore, if you require a copy of this strategy in a different format you can do so by contacting the Communications and Engagement Team. We will do our best to support and develop equitable access to all policies and procedures.

 Telephone 0161 7656 4004

 Email [email protected]

Section One - Executive Summary

This is the third annual public sector equality report for the Manchester Clinical Commissioning Groups (CCGs). As a public sector organisation, the CCGs are required to publish relevant proportionate information to show how we meet the Equality Duty. This information has to be published by 31 January each year. This report demonstrates how the CCGs are meeting its Public Sector Equality Duty in relation to services commissioned and its workforce.

The CCGs are committed to embedding Equality, Diversity and Human Rights (EDHR) within all areas of its work and, as a result of the governance review, has now set up a new internal EDHR Steering Group with clear terms of reference. The Chair will be a clinical lead representative from one of the three CCGs. This group will hold its first meeting during early 2016.

The CCGs have also refreshed their EDHR Strategy and revised their EDHR objectives, which are all aligned to the locality, strategic, and operational plans. All the above will strengthen the CCGs governance structure for EDHR. A number of work streams will be developed during 2016 to support the CCGs work towards mainstreaming this agenda.

The report highlights key demographic changes and health inequalities profile data across Manchester. This information plays a pivotal role in ensuring the CCGs are commissioning for the diverse communities of Manchester. More information can be found in Section Six of the report.

As commissioning organisations, the CCGs take EDHR seriously and, therefore, the report demonstrates how the CCGs have built EDHR into the commissioning process to ensure that, in everything they do, due regard is taken of the impact on local communities.

Section Seven of this report details a range of information and data that Commissioners use to support their decision making process. The report also details the transformational approach to commissioning that is being undertaken and how the CCGs are playing a vital role in ensuring that EDHR is built into the heart of this process.

The CCGs have a responsibility to ensure that any decision taken shows due regard of the impact on the nine equality groups, and also have due regard on health inequalities. The CCGs undertake this process by completing an Equality Analysis (EA). The CCGs have a robust process in place to ensure this happens whenever we plan, change, or remove a service, policy, or function. Quarterly workshops are delivered to support this process and the Equality and Inclusion Manager provides quality assurance checks for all EAs. Section Eight provides more details about the CCGs approach to EAs and Appendix A provides a full list of completed and signed off EAs for this reporting period.

The CCGs have developed a robust EDHR Schedule that is included in all provider contracts to ensure they comply with EDHR requirements. The schedules are tailored and proportionate in relation to the size of the organisation. Regular meetings and workshops are held to ensure compliance and understanding from Providers and assurances are given via the Quality and Performance Committee; any areas of concern are then escalated. The report sets out the specific requirements placed on providers to adhere to the EDHR Schedule. Section Nine of the report provides more details in relation to this area of work and Appendix B highlights progress on the key monitoring areas.

Workforce data is only required to be published for CCGs with over 150 employees. 4

Therefore, as CCGs with less than 150 employees, our approach is to review and monitor workforce data through our internal reporting mechanisms. Across the CCGs there is some diversity across the protected groups and the report does not highlight any real concerns in relation to how staff from the protected groups is treated by the CCGs. However, the CCGs recognise that for some protected groups the current workforce data is not as robust as it could be and, therefore, the CCGs will continue to encourage employees to declare and disclose their protected characteristics to enable the CCGs to gain a better understanding of their workforce. One of the key actions for the CCGs is to continue to develop an inclusive culture, which encourages all employees to feel confident to disclose information relating to personal protected characteristics.

The staff survey this year has included the 4 questions from the Workforce Race Equality Standard (WRES). However, the CCGs will continue to monitor their staff across the protected groups to ensure any issues or concerns are addressed through the normal HR policies and procedures. The CCGs recognise more can still be done, especially at the senior and board levels of the organisation.

The CCGs have been awarded the Two Ticks symbol “Positive about Disabled People” and will ensure this symbol is promoted on all CCG correspondence and documentation. A new Disability Policy is in its development stage and the CCGs have refreshed their EDHR Strategy and EDHR Policy during this period. The CCGs have developed a suite of learning and development opportunities for staff so that we have the right skill sets and knowledge for the challenges and demographic demands on our services. All staff have an annual Personal Development Review and all staff are required to attend the mandatory Induction programme and complete the E- Learning mandatory training; EDHR forms a key part of that process. Further information about the workforce is attached as Appendix C.

The CCGs have completed and published the Workforce Race Equality Standard WRES in line with the requirements from NHS England. Actions from the WRES will be incorporated into an over-arching EDHR Action plan.

For the second year running, the CCGs have held their annual Equality Delivery System 2 (EDS 2) external grading event. This year the focus was on Goal 1 Better Health Outcomes, the external stakeholders assessed the CCGs as DEVELOPING across Goal 1. The CCGs were graded as Developing in three areas and Achieving in two.

The external stakeholders felt there was a clear improvement from last year’s grading event and a category of Improving would have best summed up where the CCGs are in relation to evidence presented. However, they felt that we were moving in the right direction of travel and hope to see all areas as ACHIEVING next year. This means the patient data, broken down by protected characteristics, the CCGs were able to provide as evidence shows that, overall, the majority of people in three to five groups fare well when accessing a commissioned service compared with those who do not share any protected groups. Further information is contained in Section Eight of the report. A more detailed account of the grading event is attached as Appendix D.

Work is currently underway with the Communication and Engagement Team to assess the CCGs against the new Accessible Information Standard in advance of the July 2016 implementation date. This new standard will be incorporated into next year’s EDHR Schedule for providers and will be one of the key monitoring areas. Much work has been undertaken to show progress against the five EHDR objectives, Section Eleven details progress to date.

In relation to the range of engagement activities, Section Twelve of this report demonstrates how the CCGs are connecting with our communities.

The CCGs recognise that some progress has been made this year and this is supported by the feedback received from our EDS 2 external stakeholders’ event, where it was noted the CCGs had improved from previous years and that the CCGs direction of travel is positive

Notwithstanding the comments from EDS 2, the CCGs recognise much more still has to be undertaken for EDHR to be truly embedded within the CCGs. Section Thirteen of this report sets out the next steps the CCGs will be embarking on during 2016 with the aim of working towards a more inclusive and mainstreamed culture.

Section Two - Welcome Statement

We are pleased to present this year’s Annual Public Sector Equality Duty (PSED) report for the three Manchester Clinical Commissioning Groups (CCGs). This report takes into account our activities and achievements in relation to Equality, Diversity and Human Rights (EDHR) and of the legislative requirements of the PSED.

We remain fully committed to ensuring we meet and exceed our legal duties to meet the needs of our local communities and employees. We have strived to commission and deliver services that are appropriate and increasing in quality for the city’s diverse communities. Through our commissioning, we are committed to improving health outcomes, reducing inequality and reducing health inequalities.

This report brings together evidence, activities, and recommendations that demonstrate how we are meeting our statutory duties under the Equality Act 2010. We have undergone our second round of the Equality Delivery System 2 (EDS 2) and built on last year’s information; we are improving year on year and, therefore, we are on the right direction of travel. We have successfully published our Workforce Race Equality Standard (WRES) and have identified a number of actions to address the gaps, which are detailed on our website.

This year, we refreshed our EDHR strategy and undertook a review of our internal EDHR governance structure. One of the key actions arising from the review was the need to establish an internal EDHR Steering Group. It is intended that a clinical lead from one of the three CCGs will chair the group and the vice chair will be from our Joint Patient and Public Advisory Group (PPAG). This group will strengthen our existing structures and ensure we are working towards embedding EDHR at every level of the organisation, ensuring EDHR will be featured in all key business activities.

The EDHR service was also brought back in house with other HR/OD related services this year; there has already been significant improvements in this area, with a range of development opportunities available to up skill our workforce to meet the challenges of our diverse communities.

As a city, we are going through a major transformational period with our approach to health and social care. We intend to do this by improving the health and wellbeing to all the people of Manchester by closing the health inequality gap faster than the rest of the UK and integrate physical health, mental health, and social care services across Manchester. The Locality Plan is the commissioning plan for health and care integration for Manchester. It contains 3 key pillars which together will drive the radical transformation of health and care services to the residents of Manchester. These are mutually dependent and are:

 A single commissioning system  One Team  A ‘Single Manchester Hospital Service’

EDHR is an integral part of this transformation work programme and we are playing a key role by working with our partners to ensure services are commissioned and designed around a culture of support and inclusion for everyone.

As the report identifies, there have been some notable successes but there are also a number of areas where we face significant challenges and we recognise there is still much to do. We do not underestimate the challenge we face in doing this, but we recognise the high opportunity it

offers for our patients, our staff, and our local community.

We look forward to reporting on our progress in 12 months’ time.

CCG Chairs Dr. Bill Tamkin Mike Greenwood Dr. Mike Eeckelaers South Manchester CCG North Manchester CCG Central Manchester CCG

Section Three – Introduction

There are three Clinical Commissioning Groups (CCGs) in Manchester: North Manchester, Central Manchester, and South Manchester. Each CCG has its own identity, vision and structures. We work collectively across the city to ensure timely, appropriate, and accessible health services and, at the same time, respond to the needs of the community whom we serve. You can find out more about the CCGs by accessing the following link. http://www.manchesterccgs.nhs.uk/

Legend North Manchester CCG

Central Manchester CCG

South Manchester CCG

History of Clinical Commissioning Groups CCGs were created following the Health and Social Care Act in 2012, and replaced Primary Care Trusts on 1 April 2013. CCGs are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. There are now 209 CCGs in England.

Commissioning is about getting the best possible health outcomes for the local population, by assessing local needs, deciding priorities and strategies, and then buying services on behalf of the population from providers such as hospitals, clinics, community health bodies, etc. It is an on-going process, and CCGs must constantly respond and adapt to changing local circumstances. CCGs are responsible for the health of their entire population and are measured by how much they improve outcomes.

What are Clinical Commissioning Groups? CCGs are groups of General Practices and other clinicians who work together to plan and design local health services in England. They do this by 'commissioning', or buying health and care services including:

 Planned hospital care  Urgent and emergency care  Rehabilitation care  Community health services  Mental health and learning disability services

CCGs work with patients and health and social care partners (e.g. local hospitals, local authorities, local community groups, etc.) to ensure services meet local needs. CCG boards are made up of GPs from the local area and at least one registered nurse, one secondary care specialist doctor, and lay members. CCGs are responsible for arranging services within their boundaries, and for commissioning services for any unregistered patients who live in their area. All General Practices belong to a CCG.

Who are Clinical Commissioning Groups accountable to? CCGs are overseen by NHS England at a national level. NHS England is a body that ensures CCGs have the capacity and capability to successfully commission services for their local population. NHS England will also ensure that the CCGs meet their financial responsibilities.

As well as overseeing CCGs, NHS England Commissions some services itself. These are:

 General Practice  Pharmacy  Dentists  Specialist services (i.e. those required by a limited number of people)

Partnerships

Health and Wellbeing Board At a local level, Health and Wellbeing Boards have been set up in Local Authorities to ensure CCGs meet the needs of local people. Health and Wellbeing Boards bring together CCGs and local councils to understand the health, social and wellbeing needs of its community. Manchester’s Health and Wellbeing Board is responsible for leading a collaborative approach to improving the health and wellbeing of Manchester residents and reducing health inequalities.

The Board forms part of the Manchester Partnership and is also a statutory committee of the Council. The roles and responsibilities of the board include:

 Promoting partnership working and integration working across health and social care services in the city.  Leading the development and delivery of the city’s Health and Wellbeing Strategy.  Assessing the health needs of the local population through the Joint Strategic Needs Assessment (JSNA). The following link takes you to the most current copy of the JSNA. http://www.manchester.gov.uk/info/500230/joint_strategic_needs_assessment

The Health and Wellbeing Board has developed a strategy with clear strategic priorities to address inequalities across Manchester City. You can find out more about the Health and Wellbeing Board by following this link http://www.manchesterpartnership.org.uk/info/6/health_and_wellbeing_board

Public Health As Local Authorities are now responsible for public health, CCGs work closely with them through Health and Wellbeing Boards to achieve the best possible outcome for the local community by developing a joint needs assessment and strategy for improving public health. The following link takes you to the Public Health Annual Report 2014. http://www.manchester.gov.uk/downloads/download/6234/manchester_public_health_annual_re port_2014

HealthWatch Healthwatch Manchester is the independent consumer champion, created to gather and represent the views of the public. HealthWatch plays a role at both national and local level and will make sure the views of the public and people who use services are taken into account. Its mission is:

 An independent not-for-profit organisation driven by National government policy, mandated by its local membership and supported by Local Authority. Through engaging and informing the people and communities of Manchester as their consumer champion, and influencing the design and commissioning of services; Healthwatch Manchester seeks to improve their access to and experience of health and social care.

You can find out more about Healthwatch by following this link www.healthwatchmanchester.co.uk

Section Four – Governance

Governing Body Members have a collective responsibility to ensure compliance with the Public Sector Equality Duty (PSED), which will, in turn, secure the delivery of successful equality outcomes for the CCGs, both as commissioners and employers. The Governing Body provides strategic leadership to the equality and diversity agenda, which forms a key driver for delivering the key strategic objectives and vision. EDHR assurances are made to CCG decision makers via board/committee reports, which demonstrate “due regard” has taken place regarding the relevant equality groups in relation to services and employment issues.

Equality, Diversity and Human Rights (EDHR) will be monitored by the relevant Committees and they will have responsibility to ensure EDHR is an integral part of their decision making and policy development responsibilities. Any issues relating to quality or risk will be reported via the Quality Lead into the relevant Committee structures.

Regular updates will be provided to the Joint Governance Committee and Joint Executive Team on the progression of the strategy, over-arching action plan, and any other related EDHR issues across the CCGs.

The Chief Officers have overall responsibility and accountability for ensuring the necessary resources are available to progress the EDHR agenda within the CCGs. They are also responsible for ensuring the requirements of this framework are consistently applied, coordinated, and monitored.

The Head of Human Resources and Organisational Development (Head of OD/HR) oversees the implementation of the strategy, the supporting action plan, and has line management responsibility for the Equality and Inclusion (E&I) Manager and is the executive representative for this agenda.

The Equality and Inclusion Manager provides guidance, support, and advice and has day-to- day responsibility for EDHR in ensuring key EDHR work streams are delivered in conjunction with the Head of OD/HR and has responsibility for the implementation and delivery of the EDHR Strategy and action plan.

Managers of the CCGs have responsibility for ensuring employees have equal access to relevant and appropriate promotion and training opportunities, access to policies and procedures, and support their staff to work in culturally competent ways within a work environment free from discrimination, harassment, and bullying.

The CCGs have recently established a new internal EDHR Steering Group which will strengthen the current internal governance arrangements around this agenda. The chair of this group will be a clinical lead from one of the three CCG boards and the vice Chair will be from the Joint Patient and Public Advisory Group (PPAG). It is envisaged that the first meeting of this group will take place during early 2016.

Section Five – Compliance with the Public Sector Equality Duty

The Equality Act provides a legal framework to strengthen and advance equality and human rights. The Act consists of general and specific duties. The general duty requires public bodies to show due regard to:

 Aim 1 – Eliminate unlawful discrimination, harassment and victimisation  Aim 2 – Advance equality of opportunity between different groups  Aim 3 – Foster good relations between different groups

There are 9 protected characteristics covered by the Equality Act 2010 (we refer to them as equality groups); these are detailed below:

The Specific Equality Duty The CCGs are required to publish relevant, proportionate information showing how they meet the Equality Duty by 31 January each year and to set specific, measurable equality objectives by 6th April every four years starting from 2012. Both general and specific duties are known as the Public Sector Equality Duties (PSED).

As statutory public bodies, the CCGs must ensure they meet these legal obligations, and their intend to do so, by publishing information demonstrating how the organisation has used the Equality Duty as part of the process of decision making in the following areas:

 Information – details of information taken into account when assessing impact See Section Seven below (EDHR in Commissioning- evidence based approach to commissioning)  Service delivery – evidence of equality analysis that has been undertaken See Section Eight below Decision Making (Equality Analysis)  Workforce – an analysis of workforce and employee related issues are detailed in Section Ten below  Connecting with our Communities – details of communication and engagement activities that have taken place during this period can be found in Section Twelve below.

Other Key Equality, Diversity and Human Rights Drivers The Human Rights Act 1998 is core to the rights of patients, as set out in the 1NHS Constitution. The CCGs will endeavour to embed a human rights based approach in the way we commission services and in our role as an employer. Human Rights are underpinned by a set of common values and have been adopted by the NHS under the acronym FREDA. We will use the FREDA principles in our Equality Analysis documentation to ensure our decisions are made with due consideration of human rights. The principles represent:

 Fairness – Right to a fair trial (e.g. fair and transparent grievance and complaints procedures)  Respect – Right to respect of family and private life (e.g. respect for same sex couples, teenage parents, homelessness)  Equality – Right to not be discriminated against in the enjoyment of other human rights (not being denied treatment due to age, sex, race, etc.)  Dignity – Right not to be tortured or treated in an inhuman or degrading way (e.g. sufficient staff to change soiled sheets, help patients to eat/drink)  Autonomy – Right to respect for private life (e.g. involving people in decisions about their treatment and care)

Health and Social Care Act 2012 The Health and Social Care Act 2012 introduced legal duties to reduce health inequalities for CCGs. As a CCG, we are now required to consistently ‘have regard’ to the need to reduce inequalities between patients in access to health services and the outcomes achieved. In exercising their functions—with a view to securing that health services are provided in an integrated way and are integrated with health-related and social care services, where they consider this would improve quality and reduce inequalities in access to those services or the outcomes achieved. The CCGs have incorporated health inequalities into their current Equality Analysis template to assist with the decision making process.

Equality Delivery System 2 Although the Equality Delivery System 2 (EDS 2) is not a legal requirement, it is a mandatory requirement for all NHS organisations. EDS 2 aims to help NHS organisations in discussions with local partners and stakeholders’ review and improve their performance for equality groups protected by the Equality Act 2010.

EDS 2 also supports the CCGs in meeting and delivering the requirements of the PSED. This strategy and action plan is aligned to the EDS 2 goals and outcomes. More information about EDS 2 can be found in Section Eleven below.

Workforce Race Equality Standard Since 1st April 2015, NHS organisations are required to respond to the NHS Workforce Race Equality Standards (WRES), in regards to their workforce. We already monitor our workforce under the PSED and publish for those with more than 150 employees, however, some organisations have a historically poor record in collecting and publishing data on equality, including race equality. Therefore, the WRES has now been included in the 2015/16 NHS Standard Contact. The WRES forms the first phase in a programme of work addressing workforce equality issues. The CCGs have developed a range of actions to address issues arising from the WRES; these are incorporated into the EDHR Action Plan. More information about the WRES can be found by following this link https://www.england.nhs.uk/about/gov/equality-hub/equality-standard/ http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Pages/Overview.aspx 14

The CCGs have adopted the social model of disability and ensure barriers, that restrict life choices for disabled people, are removed. They also ensure a more inclusive way of living is developed through our interaction with patients, carers, service users, and employees. The CCGs have recently developed a specific disability policy for employees and has been awarded the Two Ticks Symbol, which demonstrates we are Positive about Disabled People.

The CCGs will also ensure all information is accessible and that appropriate Communication support is provided to meet the needs of patients, service users, and carers. They will, therefore, ensure they comply with the requirements of the Accessible Information Standards and will also monitor their providers against this standard on an annual basis. More information about this standard can be found by following this link. https://www.england.nhs.uk/ourwork/patients/accessibleinfo-2/

Section Six – Manchester Demographics and Health Profile

Over the last decade, Manchester has been the fastest-growing city in the UK. The City Council’s forecasting model predicts population growth in Manchester to rise to between 543,100 and 577,800 by 2021. In contrast to the national picture, Manchester has a comparatively young population. Currently, nearly two-fifths (39%) of the population is aged under 25, compared with around 31% in England as a whole. A mere 10% of the population is aged 65 and over, compared with 17% in England.

Manchester’s population has a younger age profile than the national average, with its working age population boosted by the large number of students in the city.

Manchester’s older population is almost unique in England. Older people form a smaller than average proportion of the population and the number of people aged 65 and over is currently decreasing, set against an above average number of young adults. Having fewer older people in a population might be thought to lead to a reduced need for services; however—given that many older people are the bedrock of the voluntary sector and provide huge amounts of care and support to family members and others - the impact of these lower numbers may be detrimental to Manchester’s wellbeing. Additionally, whilst there are some settled communities of older people, many live in areas where they experience higher levels of social exclusion and many report very poor health and loneliness.

The characteristics of Manchester’s older residents also means they are more likely to place high demands on hospital emergency services, mental health services, and that they suffer from long-term limiting illnesses at an earlier stage in their old age than seen nationally. In response to this, the city has launched the Living Longer, Living Better initiative, with a goal of health and social care integration, and Age-friendly Manchester, a wide-ranging programme affiliated to the World Health Organisation.

Data from the 2011 census also shows the population of Manchester has become more diverse in the past decade, with a reduction in the proportion of residents classifying themselves as coming from a White ethnic group (from 81% in 2001 to 66.6% in 2011). In some parts of the city, more than two-thirds of the population classify themselves as coming from a non-White ethnic group. Around 45% of live births, to women resident in the city, are now to mothers born outside the UK (up from just 25% in 2001).

Since 2011, the proportion of the Manchester population who are from Black and Minority Ethnic groups (BME) has increased from 19% to 33.4%. The proportion of residents within the broad BME groups (Mixed, Asian, Black, and Other) have increased in Manchester between 2001 and 2011, with the Asian group in particular growing from 10.4% in 2001 to 17.1% in 2011. The proportion of residents in the White broad group in Manchester has fallen 19.4 percentage points below the average for England and Wales, and 23.6 percentage points lower than the North West.

Manchester is famed as a multinational and culturally diverse city, having long been a centre for inward migration. Researchers at Manchester University claim Manchester to be the UK’s language capital, with over 200 languages spoken by its long-term residents. After English, the most commonly spoken languages in Manchester are: Urdu; Arabic; Chinese; Bengali; Polish; Panjabi; and Somali, reflecting recent immigration patterns. Of our residents for whom English is a second language, 80% report they speak it well or very well, with only 3% reporting they cannot speak English.

Manchester’s economy has continued to recover from the impacts of the recession, with 16

businesses reporting increasing levels of confidence. However, although the number of residents in employment has increased, employment rates are still notably lower than the national average, and youth unemployment is still a cause for concern. Educational attainment levels in parts of the city are lower than the national average and this, coupled with a large amount of low paid or part time employment, means many families are trapped in benefit dependency. One of the priorities for the city is to focus on improving employment and skills, in order for all residents to benefit from the many opportunities available, and that poverty whether in or out of work is reduced. We are seeing results in this area, with our GCSE 5 A*-C rate improving, and many more opportunities emerging for young people to remain in education and training.

Despite recent improvements, the health of people living in Manchester remains among the worst in England, with life expectancy remaining stubbornly low and with the city showing a high number of preventable deaths.Our under-75 mortality rates for both cancer and cardiovascular diseases are among the very worst in the country. All the modifiable lifestyle factors that lead to poor health outcomes are highly prevalent in Manchester: high numbers of overweight or obese children; high recorded levels of drug misuse; high levels of alcohol use; and poor diets. Although smoking rates at 24.6% are higher than the England average of 19.5%, they are some way from the national worst of 30.1%. Despite this, we have the highest number of smoking related deaths in the country, possibly reflecting higher smoking rates in the past, and/or late access to diagnosis and treatment. One very encouraging sign is our progress in reducing the number of women who are smoking in pregnancy.

This has dropped to 12.6%, matching the England average, and has been coupled with significant success in introducing ‘Smoke Free Homes’ across the city. Our success in early years’ interventions can also be seen in our improving rates of breast feeding initiation. We can take some hope from our improving indicators in relation to children’s health and attainment for the health of our future citizens.

In order to reduce the burden of ill health in Manchester and to reduce the life expectancy and healthy life expectancy gap we see in the city we must address the underlying causes of this ill health. To achieve this, we will need to support people to make healthier choices: work to make the healthier choice become the easier choice and ensure our population can access services in a timely manner, so that interventions are as effective as possible.

The low uptake of preventative services (whether screening, immunisations, or health checks) and the late presentation of symptoms to GPs or other healthcare professionals, are all more common in our populations living in more disadvantaged areas. This low uptake and/or late presentation all add to the poor health outcomes in these groups. We know that, for example, diabetes rates are higher in some BME groups and that, therefore, the health impact of obesity is likely to be greater in these groups. But, at the moment, we are not able to demonstrate we are consistently targeting these higher risk groups for preventative activity or that such targeting is effective. Similarly, our HIV prevalence rate in Manchester is one of the highest in the country, with particularly high rates among sub-Saharan Africans and gay men.

However, our HIV testing is not well embedded and routine and so we continue to have a high proportion of people diagnosed at a point at which their illness is already starting to have clinical implications for them. This is dangerous both for the individual involved because of the implications for their treatment and life expectancy but also for the wider population as a longer time pre-diagnosis may increase the risk of onward transmission. Despite the fact that we know a lot about the different prevalence of this condition among different groups, our delivery and targeting remains inconsistent, with much remaining dependent on the knowledge and skills of

individual clinicians.

In order to achieve a more consistent approach to the delivery of preventative services, and better uptake among higher risk groups, we are focusing on two key policy drivers. The first is to deliver Public Service Reform so our services are modernised to tackle complex dependency, enable all children to get the best start, support the integration of health and social care, and target those most in need. The second is to deliver against the Public Health Outcomes Framework for England, 2013-2016, with its vision of improving and protecting the nation’s Health and Wellbeing, and improving the health of the poorest fastest: clearly a particularly relevant goal for Manchester.

Within this, we are particularly focusing on where we see the largest discrepancies between different areas and sub-populations, so that we can address both life expectancy gaps between Manchester and the UK, and also address the gaps between different areas of, and groups within, Manchester.

Section Seven – Equality, Diversity and Human Rights in Commissioning – (evidence base approach to commissioning)

Manchester CCGs are clinically led commissioning organisations, meaning local clinicians are responsible for buying healthcare from a range of providers who are then contractually required to provide these services to the local population of Manchester. These include urgent and emergency care, planned non-emergency hospital care, community health services, and mental health and learning disabilities.

Challenge The NHS is facing an unprecedented level of future pressure, driven by: an ageing population; increase in long term conditions; rising costs; public expectations; and a challenging financial environment. To address these challenges, it is increasingly important Manchester CCGs work more closely with our partners to achieve efficiencies, whilst improving quality and patient experience.

Ambition Partners across Manchester have responded by coming together to produce a Locality Plan which sets out the five year ambition for improving health and social outcomes across Manchester. By 2021, residents of Manchester will:

 Benefit from a transformed, integrated health and social care system in which they receive health and care interventions which are joined up, of high quality, and are affordable.  Be supported and encouraged to do what they can to remain healthy.  Live in a City which encourages them to make the right choices.  Ensure that when they need access to more specialist support they receive it in the right place at the right time, appropriate to their needs and wishes.

Locality Plan Transformational Programmes A number of transformational initiatives have been developed to achieve the Locality Plan. The initiatives focus on: public health; cancer care; primary care; integrated community-based care (Living Longer, Living Better); mental health; learning disability; shared services across the acute sector; children and young people; and housing and assistive living technology. The opportunities arising from the Greater Manchester Devolution Programme will help deliver these transformations by allowing greater local control of how the entire budget on health and social care is spent in Manchester. The link below takes you to the Locality Plan. http://www.manchester.gov.uk/meetings/meeting/2377/health_and_wellbeing_board

Operational Plan The annual Operational Plan all CCGs are required to produce each year will focus its commissioning activity on delivery of year 1 of the Locality Plan transformational programmes, as well as delivering against our constitutional standards and statutory requirements for the 2016/17 financial year. The 3 CCGs across Manchester have agreed to develop one Operational Plan across Manchester for 2016/17.

Equality, Diversity and Human Rights in Commissioning The CCGs want to place equality and inclusion at the heart of commissioning services for local people from vulnerable protected groups. The CCGs have made some progress in transparently embedding EDHR into its decision making processes and this will be increasingly reflected in the redesign of existing services and the commissioning of all services. The diagram below illustrates the key components of mainstreaming equality and inclusion into the commissioning cycle. 19

EDHR is at the heart of commissioning:

 Ensure all CCG staff (including new starters) and providers have received training in how to embed EDHR into day-to-day practices.  Ensure providers monitor fair access to services by protected groups and differential satisfaction levels. Build equality returns into contract reviews.  Build EDHR criteria into all contracts e.g. EDHR Schedule of evidence and EDS 2 performance framework.  Involve all protected groups in service design and re-design.  Show “due regard” – undertake Equality Analysis and Human Rights screening on: early decisions; priorities; Commissioning Intentions; programmes; strategies; and policies, where appropriate.  Specify required equality Outcomes within service specifications.  Engage local protected groups to identify health needs and any negative impacts on protected groups from healthcare changes under consideration by the CCGs.

Key information and data (evidence base) Commissioners use a wrath of data/information to aid them when commissioning and procuring services; some of the key demographics, health inequalities, and engagement information can be accessed via the following links:

 Compendium of statistics provides more detailed information on North Manchester’s health inequalities, socio economic factors and three of the protected characteristics: age, gender, and ethnicity. http://www.manchester.gov.uk/downloads/download/5724/compendium_of_statistics- manchester  The Joint Strategic Needs Assessment (JSNA) provides a baseline assessment of needs across North Manchester and is a key piece of evidence underpinning the development of the joint Health and Wellbeing. NHS and local authority commissioners will be expected to have given due regard to the JSNA and Joint Health and Wellbeing strategy when developing their commissioning plans. Follow this link to find out more about the JSNA http://www.manchester.gov.uk/jsna  Manchester’s State of the City 2015 report provides a yearly snapshot of the city’s progress towards the vision for a world class city as set out in the refreshed Community Strategy. The report presents an overview of performance against a number of indicators: e.g. diversity and ethnicity; socio-economic factors; cohesion; and migration, etc. A full copy of the report can be found by following the link. http://www.manchester.gov.uk/SoC2015  Communities of interest - The Manchester Partnership (Manchester’s Local Strategic Partnership) bring together key sectors, organisations, and community representatives who are tackling the toughest problems residents say affect their lives. In doing so, the Partnership is delivering its Community Strategy for Manchester, which outlines its vision for a world-class city by 2015, when Manchester people will live longer, be wealthier and be happier. The following link takes you to the latest communities of interest report. http://www.manchesterpartnership.org.uk/manchesterpartnership/downloads/file/303/com munities_of_interest_2014  Public Health Report 2014 – Presents an overview of the demographics and health profile of the communities of Manchester. A copy of the full report can be accessed by following this link. www.manchester.gov.uk/.../id/18302/7_public_health_annual_report  Census 2011 – Census statistics help paint a picture of the nation and how we live. They provide a detailed snapshot of the population and its characteristics and underpin funding allocation to provide public services. The census is divided by a range of themes and is also broken down by cities and neighbourhoods. Further information can be found by following this link. http://www.ons.gov.uk/ons/guide-method/census/2011/census- data/index.html  LGBT Foundation – This website has a wealth of information Commissioners can access to obtain health and demographic information about the LGBT community within Manchester. The following link details the wealth of information at the disposal of CCGs. https://lgbt.foundation/  The Equality and Human Rights Commission provides a range of EDHR resources as well as undertaking a number of specific research programmes that are published and supports the CCGs in understanding the communities it serves. http://www.equalityhumanrights.com/  The Business Intelligence Team is based within the CCGs and provides Commissioners with a wealth of data about the local population, particularly at primary care level.  Communication and Engagement – see Section Twelve below.

Section Eight – Decision Making (Equality Analysis)

The CCGs are committed to ensuring the organisations pay due regard to the three aims of the Public Sector Equality Duty (PSED). The systematic analysis of the impact of our actions and decisions on equality is one way this can be achieved.

The CCGs believe the Equality Analysis (EA) process is central to being a transparent and accountable organisation. The EA ensures we do not disadvantage people from protected and marginalised groups by the way we commission health services. The EA help us to develop a better understanding of the communities we service. EAs are an integral part of the business case and policy development and, as such, they are required to be completed whenever we plan, change, or remove a service, policy, or function.

Our process requires individual staff and teams to think carefully about the likely impact of their work on different communities or groups. It involves anticipating the consequences of the organisations strategies, policies, procedures, and functions on different communities and making sure any negative consequences are eliminated or minimised and opportunities for promoting equality are maximised.

As CCGs, we also have a responsibility under the Health and Social Care Act 2012 to “have due regard” to the need to reduce health inequalities when exercising our functions.

Our Equality Analysis Toolkit assists managers in undertaking analysis, which now incorporates a section on addressing health inequalities. The Toolkit aims to make the process of equality analysis easier to understand and implement and is designed to make it as simple as possible for the analysis to be completed.

The CCGs deliver quarterly EA workshops for managers who are required to undertake an EA. This year we delivered 4 workshops, with 31 members of staff attending. A full list of all completed EAs for this reporting period are listed in Appendix A.

Section Nine - Performance Monitoring of Providers

As CCGs, we have in place mechanisms to ensure provider organisations comply with their equality duty. We have developed a suite of EDHR Schedules, which forms part of the overall provider contract. These were refreshed this year and now have a suite of schedules which are tailored to provider organiser size, as we recognise one size does not fit all.

As mentioned above, the schedules are based on workforce size and, therefore, the following criteria are used to determine which schedule will be applicable for each organisation.

Provider Size (workforce) EDHR Schedule 1 – 5 workforce Schedule 1 5 – 49 workforce Schedule 2 50 – 150 workforce Schedule 3 150+ workforce Schedule 4

As CCGs, we monitor provider workforce and service delivery activity in relation to the PSED; included in the Schedules is the requirement for providers to demonstrate compliance with NHS England mandatory requirements: e.g. EDS 2; WRES; and Accessible Information Standards, as a minimum.

The EDHR Schedules are monitored on a quarterly basis by face-to-face meetings with the Equality and Inclusion Manager who then reports to the quarterly Quality and Performance Committees on progress against the schedule; any areas of concerns are escalated.

For small providers, regular workshops are held for providers to understand what is expected from them in relation to the schedule. As mentioned, the schedules are tailored to specific organisation size; therefore, the requirements are in proportion to the contract and also the size of the provider. The key areas of the contract are detailed below:

Large Providers Small Providers (depending on size) Workforce Information (including Annual Equality Report (including, training, E&D training) policy/Strategy, workforce data and patient or service delivery data summary version). Tribunal cases i Equality & Diversity Policy/Strategy Workforce and Service Access Report Access Tribunal cases Communication and Engagement (including engagement with stakeholders around E&D performance) Annual Equality Report

Access to Services (including accessible information standard) Communication and Engagement

Reasonable adjustments (anticipatory duty) Patient Experience and Complaints Sub-Contracting EDS 2 and WRES Human Rights Assurances Website

Appendix B details the high level assurances required from Acute Providers; further information can be found on Provider websites.

Section Ten – Workforce

As part of the requirement of the PSED, organisations with over 150 employees are required to publish information relating to their employees. Where our workforce is less than 150, our approach is to review and monitor workforce data through our internal reporting mechanisms. A full copy of the CCG workforce report is attached as Appendix C, where applicable.

The CCGs have set out, in their EDHR Policy, clear responsibilities and behaviours employees must adhere to. Employees have a personal responsibility for their own behaviour and must treat their colleagues, service users, carers, and members of the public with dignity and respect.

Section Eleven – Equality, Diversity and Human Rights Objectives

We have refreshed our objectives in line with the refreshed strategy and, therefore, have set ourselves some key deliverable objectives to move us forward during 2015 – 2018.

We will be developing an action plan, which will set out clear actions the CCGs will be delivered during 2016/17; with a view that the plan will be updated each year to reflect key priorities. The plan will be monitored by the Internal EDHR Executive Steering Group; each objective will be assigned to a member of that group and actions will incorporate issues arising from the key work streams identified within this report.

The EDHR Strategic objectives are:

Objective 1: To increase the awareness of the EDHR Agenda across CCGs, their members, and providers  The CCGs will ensure all staff have a full understanding of their roles and responsibilities under the Equality Act 2010.  That general practice staff are aware and can respond to the needs of the local equality groups. Objective 2: To improve data collection and usage across all equality groups  Ensure commissioners use evidence based data to assist with their commissioning decisions across all activities and equality groups.  That information is collected, shared, and stored in accessible formats via a data hub. Objective 3: - To ensure effective communication, engagement, and involvement tools are available and accessible for all of our communities  The CCGs will ensure under-represented groups are effectively informed and involved in the decision making process of the CCGs in relation to health care.  The CCs will have in place a range of communication, engagement and involvement tools to ensure total inclusion for all. Objective 4: To ensure all commissioned Providers have robust standards in place in respect of EDHR and have plans in place to make improvements  To have in place robust standards and systems to meet the EDHR Schedule.  To ensure robust action plans are in place to address any gaps. Objective 5: To ensure all CCGs have inclusive leadership, and an engaged and represented workforce  The CCGs will provide vision and strong leadership to lead on this agenda.  The CCGs will work towards creating a workforce that is fully reflective of the diverse communities.  We will ensure OD Programmes reflect and communicate the CCGs’ commitment to this agenda, whilst enhancing and developing knowledge and skills.  CCGs will ensure key policies and procedures are in place to support the CCGs achieve their aims.

EDHR Work-Stream Progress The following work streams have supported the CCGs in meeting their objectives:

Objective One  Mandatory E-learning – Equality Awareness.  The CCGs have a quarterly rolling programme of Equality Analysis workshops.  Monthly Induction training, where EDHR is a key element of that programme.  Development of a new EDHR policy, with a specific section around commissioning services.  Introduction of a specific disability policy for employees.  A range of lunchtime learning events have been established for staff to attend to raise awareness around specific health issues, health inequalities, and the protected characteristics.  In-house management Development programme; EDHR is integrated throughout all the modules of this programme.

Objective 2  Improvement in the range of data sets Commissioners are using to aid them in understanding their local population – as detailed in Section Seven above.

Objective 3  Accessible Information Standard – The CCGs are working with their joined Communication and Engagement team to benchmark against this standard and will introduce any necessary actions in advance of the implementation date of July 2016. We will be incorporating these new standards into the refreshed provider EDHR Schedule for 16/17. The CCGs have updated their websites and introduced a new intranet site for staff members; both have specific pages on EDHR. The sites are accessible and meet with the national standards.

Objective 4  EDHR Schedule – We have refreshed and updated our EDHR Schedules, which are now tailored to meet the specific requirements of providers depending on their size. The E&I Manager holds quarterly meetings with the Acute Providers to assess them against the schedule and provide assurances to the Quality and Performance Committee and Boards. Any concerns are reported formally through these reporting processes. Most recently, an event was delivered for smaller providers to provide them with support and set out expectations around the schedule. It is intended this will happen for all smaller providers during 2016 and then regular refreshers will be provided to ensure compliance.

Objective 5  EDHR Strategy – The CCGs have refreshed their EDHR Strategy, which outlines our plans during 2015 – 2018 to eliminate discrimination, reduce inequalities, and improve health outcomes for all who live and work in the city. The strategy is aligned to the five equality objectives, the EDS 2 system, and the NHS WRES. The strategy can be found via this link under publications http://www.manchesterccgs.nhs.uk/

 Governance – As a result of a governance review of EDHR, the CCGs have established an EDHR Steering Group; the chair will be a clinical lead, drawn from representatives from the three boards, and the vice chair representation from the Joint PPAG group. Members will be from across the senior management team and will report directly into the three CCG Boards; the group will be accountable for this agenda, it is intended the first meeting will take place during the early part of 2016. 27

 Equality Delivery System 2 – EDS 2 is a mandatory requirement for all NHS organisations to assess its performance against EDHR. This is the second year the CCGs have undertaken this assessment and this year the focus was on Goal 1 Better Health Outcomes.

 The CCGs successfully carried out an engagement event with local stakeholders and staff in order to verify the internal assessment and processes. External stakeholders graded the CCGs with the following:

Equality Delivery System 2 - Goal 1 Better Health Outcomes

Outcome Grading Score 2015 1.1. Services are commissioned, procured, designed, and delivered to meet the health needs of local Achieving communities 1.2. Individual people’s health needs are assessed and Achieving met in appropriate and effective ways 1.3. Transitions from one service to another, for people on care pathways, are made smoothly with everyone Developing well-informed 1.4. When people use NHS services, their safety is prioritised and they are free from mistakes, Developing mistreatment, and abuse 1.5. Screening, vaccination and other health promotion Developing services reach and benefit all local communities

 The CCGs were graded as Developing in three areas and Achieving in two. The external stakeholders felt there was a clear improvement from last year’s grading event and a category of Improving would have best summed up where the CCGs are in relation to evidence presented. However, they felt we were moving in the right direction of travel and hope to see all areas as ACHIEVING next year. Therefore, based on the assessment, the overall grading for Goal 1 is DEVELOPING. This means the patient data, broken down by protected characteristics, the CCGs were able to provide as evidence shows that, overall, the majority of people in three to five groups fare well when accessing a commissioned service compared to those who do not share any protected groups. A copy of the full report is attached as Appendix D.

 Workforce Race Equality Standards – From 1st April 2015, NHS commissioned providers were required to publish results of the NHS Workforce Race Equality Standards. The standard requires us to demonstrate progress against a number of indicators of workforce equality. There are nine metrics; four of the metrics areas are based specifically on workforce data and four are based on data derived from the national NHS Staff survey indicators. We do not currently undertake the NHS Survey, but, as best practice and to comply with the benchmarking of the standards, we have incorporated the survey questions into our annual staff survey. Survey results can be found in the Workforce section of this report. The final metric looks at the representation of boards. A copy of the CCGs’ report can be accessed by the following link http://www.manchesterccgs.nhs.uk/

 Two Ticks Symbol – Most recently, the CCGs have been awarded with the Positive about Disabled People Two Ticks Symbol. The CCGs are required to demonstrate evidence around 5 point criteria. This symbol highlights how the CCGs are positive about encouraging and supporting disabled people in the workplace. The symbol will be promoted on all our external and internal recruitment documentation. It is intended we will continue to build on the progress made this year in working towards meeting the overall objectives.

Commissioning Alternatives to Transfer – The development of the Pathfinder Tool has enabled North West Ambulance Service (NWAS) to work with other services to provide alternatives to hospital transfer. The use of the Pathfinder Tool identifies patients that are safe to be left at home, subject to another service being available to continue appropriate assessment and care of patients in a timely manner. This is particularly beneficial for lower acuity patients, particularly those who are elderly who currently are taken to A&E and often admitted. A dedicated GP service is in place as an alternative to hospital transfer to A&E. This supports:

 Reductions in emergency ambulance activity.  Reductions in A&E attendances.  Reductions in hospital admissions.

An example of improving equality and diversity through the small provider framework – The CCGs have introduced a framework for the monitoring of small providers (these are contracts of a certain financial value—usually private providers delivering minor surgery, diagnostics etc. This framework includes performance metrics, quality standards and walkrounds of these providers. This case study sets out improvements made to a small provider following on from the introduction of these quality standards.

Influenza vaccination of children – An annual seasonal influenza vaccination has been introduced for younger children over recent years, extending this year to primary schools. This will protect the vaccinated children directly but also, through ‘herd immunity’, the wider community, including those in protected and disadvantaged groups who are often the most vulnerable to the impact of influenza. The herd immunity impact has already been seen to be greater than originally envisaged. When the children flu vaccination programme is fully rolled out, a substantial population fall in annual seasonal influenza can be reasonably expected, which will benefit the entire population.

IRIS Domestic Violence and Abuse Support Service – The CCGs have commissioned an education and support service to GPs in relation to the identification of patients who may be at risk of, or experiencing, domestic violence or abuse. This case study sets out how this was developed and the impact it has had across the three Manchester CCGs.

Learning disability – National data sets out the continuing problems for patients with a learning disability in accessing—and integrated working between—primary, secondary, and specialist health services. This case study sets out the quality improvement scheme put in place across providers to improve safety and experience for this patient group.

The Manchester Pathway for Homeless People service (Mpath) works with homeless patients accessing urgent care services at Manchester Royal Infirmary by providing:

 Specialist multidisciplinary care for homeless patients in A&E or on MRI wards.  Support for safe and effective discharge.  Liaison with relevant organisations and services to secure effective on-going care. These include substance misuse, alcohol, mental health, and housing services. Encouragement for Mpath patients to register with a GP practice (the majority is expected to register at Urban Village but patients have been offered information to support choice).  Proactive primary care management for Mpath patients registering at Urban Village.

One Team – Living Longer, Living Better (LLLB) describes the ambitious programme of work aimed at ensuring local people receive high quality, personalised services. These services support them to manage their own health and wellbeing and live long, healthy lives. This will be delivered by the organisations responsible for improving the health and wellbeing in the city working together to develop and deliver integrated services.

By 2020, LLLB will have radically transformed Manchester’s community-based care system. This transformation will support people to live longer, healthier lives by ensuring a wide range of high quality health and social care services are easily accessible within communities, and are centred on the individual and their specific health needs. The aim is for 20% of care, currently being delivered in hospital, to be delivered in the community in future.

LLLB is founded upon the development of vastly improved integrated working between health and social care workers and organisations. The programme will be delivered by health and social care professionals organised around 12 hubs across the city, each serving 40-50,000 people. This arrangement, and the organisational changes needed to make it happen, is being called One Team.

The One Team will be implemented from 1st April 2016 and will be commissioned on a population basis. This is a programme of work over five years, to reach the 2020 vision.

Personalised Health Budgets (PHBs) – Since April 2014, people have had a right to ask, and since October 2014 have a right, to have PHBs. The outcomes are not based on medical outcomes we have always looked at; they are much more based on real life outcomes, being able to do something rather than ‘hitting a target’. The PHBs present an opportunity for an individual to become proactively involved in their own healthcare planning. The process draws together both clinical expertise and the patient’s ‘lived expertise’; it puts patients in the driving seat and allows them to procure care and equipment according to their own needs and timetable. The person’s allocated budget should not exceed the amount estimated for conventional NHS service delivery.

Pharmacy Minor Ailments – The Minor Ailments Scheme enables patients access (with no appointment necessary) to advice and, if necessary, medication for minor ailments e.g. headaches, indigestion etc. The scheme is supported by GPs across Manchester and is accessible at community pharmacies throughout Manchester. For selected patients, where the pharmacist deems it clinically indicated, medication is provided free-of-charge.

Pressure Ulcers for Adults – A review of pressure ulcers highlighted that these were predominantly occurring in patients over the age of 65 with multiple co-morbidities, and that nutritional needs that were highlighted as a theme through the deep dive were not being addressed in any of the action plans developed. This case study sets out what was done to address this and how this work is now being used to influence change at a Greater Manchester level for these vulnerable patients. 30

Pride in Practice – Pride in Practice is a quality assurance service for GP practices and their lesbian, gay and bisexual patients within their local communities. It was developed because studies have shown lesbian, gay and bisexual people experience disproportionate health inequalities. LGB people are at greater risk of preventable life limiting conditions, are more likely to smoke and use drugs and/or alcohol, and are disproportionately affected by eating disorders and mental illness.

Pride in Practice worked with GP practices across North, Central and South Manchester CCGs to: increase clinicians’ knowledge and confidence when treating LGB patients; improve visibility of LGB people in GP practices; introduce sexual orientation monitoring, so that practices can better understand the needs of their patient populations; and support practices to deliver targeted health promotion campaigns for lesbian, gay and bisexual patients, improving overall health outcomes for their LGB patients.

 One in 10 lesbian, gay and bisexual patients say their sexual orientation is a factor in them delaying accessing health services (Richardson 2010).  One in 4 lesbian, gay and bisexual people are not out to any health professionals (LGBT Foundation 2014).  Lesbian, gay and bisexual patients are twice as likely to report they have no trust or confidence in their GP or nurse (National GP Survey 2014).  If people have experienced discrimination at any point, their fear of further discrimination will often prevent them from speaking out (D. Herda 2013).

Social Isolation – One of the major issues facing Manchester is the loneliness and isolation of older people. Loneliness causes high levels of emotional distress. Without early support and intervention, social isolation and loneliness can cause older peoples’ health to deteriorate and increases the need for more intensive forms of support from health and social services in the long term.

Section Twelve – Connecting with our Communities

We know that diversity and inclusion leads to improved health and greater experiences of the NHS.

Throughout April 2014 and March 2015 we have engaged and worked in partnership to better understand the health inequalities and needs of citizens living in Manchester and take action to ensure a better experience of care.

Promoting equality and equity are at the heart of our values, ensuring that we exercise fairness in all that we do and that no community or group is left behind in the improvements that will be made to health outcomes in Manchester.

Our engagement work is intelligence led and activities and partnership working is driven by the key priorities of the operational plans for the three Manchester Clinical Commissioning Groups as well as alignment to the Manchester Locality Plan.

We ensure that all of our engagement activities include the collection of demographic information to ensure inclusion of all protected characteristics. Our monitoring demographics form has recently been updated to reflect the “Monitoring Equality and Health Inequalities: A Position Paper” from NHS England. By reviewing this and other patient/service user experience information, we are able to prioritise our work with protected characteristics and local communities.

Our volunteer base is continuing to expand and there are several ways in which patients, carers and the public can be involved in the co-production and co-design of our work. Opportunities include:  Joining our Patient and Public Advisory Groups  Becoming a volunteer for the Macmillan Cancer Improvement Partnership  Joining our Expert Panel

We are currently updating our demographic information for all of our volunteers so we can target our recruitment to specific protected characteristics, communities and groups.

Volunteers throughout the year have been integral to sharing experiences from their use of health and care services and from their own networks in the community. We will continue to develop these mechanisms to inform and influence commissioning decisions across all three organisations.

An intelligence hub for CCG commissioners is being developed as a starting place for staff to understand the needs of protected characteristic groups. This is due to go live in spring 2016 and will include local and national reports/information on the needs of protected characteristic groups. It will also include patient experience findings on long term conditions and other priorities as set out in the Manchester Locality Plan. It will provide commissioners with a better understanding of needs and will highlight any gaps information which will inform future engagement and partnership working.

Here are examples of connecting with our communities to tackle health inequalities:

Impact of dementia on Black, Asian and Minority Ethnic communities GP Helen Martin, clinical lead for dementia, wanted to listen to patients, carers, and the public to better understand the impact dementia has on the Black, Asian and Minority Ethnic communities in central Manchester. A ‘GP Listening Event’ was held to provide the opportunity for GP Helen Martin to listen to—and have an open space to talk directly to—carers, voluntary sector organisations, and members of the public on this topic. We worked in partnership with 32

Donna Miller, Community Empowerment Officer at the Manchester Race and Health Forum, to invite people living and working in central Manchester to share their experiences.

The key issues which were shared at the listening event were around:

 Diagnostics and assessment.  Lack of an evidence base around dementia and its impact on Black, Asian and Minority Ethnic communities.  The need for further engagement with local communities and understand how dementia affects different groups and the cultural differences.  Carer support.  Patient and carers experiences being collated and used to inform decision making.  Communication and information.  Access to services.  Community awareness of the symptoms of dementia.

Feedback from the event has been used to inform the review of the city-wide dementia strategy and further engagement with Manchester BME Network. Feedback was also used to inform the development of a person-centred coaching skills training package for health and social care staff.

A copy of the report is available from the Communications and Engagement team by calling 0161 765 4004 or by emailing [email protected].

Partnership working with the University of Manchester Students Union to engage with students We commissioned the University of Manchester Students Union, in March 2015, to engage with students so we could better understand the health needs of students in Manchester and the barriers to accessing health services. There was a delay in the work taking place; it did not start until October 2015. To date, a student questionnaire has had over 600 responses with an additional 350 street interviews carried out. Focus groups and one-to-one interviews are also taking place. An engagement report is due back to Manchester CCGs during January 2016.

Responding to patient needs for translated information The Manchester Integrated Care Gateway responded to a request from a GP practice for patient information leaflets to be translated into Cantonese and Polish languages. The service was supported to externally source translated versions of the patient leaflet and these were made available to all GP practices across the city in the following languages: Cantonese, Urdu, Arabic, Polish and French.

Choose Well Manchester Choose Well Manchester is a website which offers advice and support about when and how to use local health services. The website information can be translated in over 60 languages and we are continuing to promote the website at community events, meetings, and with our partners across health and social care.

Following engagement activity with Black and Minority Ethnic (BME) communities in partnership with the Black Health Agency, a need was identified for video information on what to do when you are feeling unwell in Manchester. Working in partnership with local GPs and practice staff—who speak Bengali, Urdu, Punjabi, and Arabic—a series of videos were developed with the aim of increasing awareness of what to do when feeling unwell. The videos can be viewed via this link. http://www.choosewellmanchester.org.uk/self-care/ 33

Raising awareness of the Macmillan Cancer Awareness Partnership (MCIP) It was recognised, from our engagement work, that we needed to engage with communities and individuals where English may be a second language. The MCIP User Involvement Facilitator worked with local interpreters to translate audio clips with the first one promoting the involvement opportunities in MCIP and the second one advertising one of our Cancer Experience Forums held during 2015. The audio clips were recorded in five languages: Urdu, Hindi, Punjabi, Farsi and Romanian. The clips can be listened to via our SoundCloud account: https://soundcloud.com/mcipmcr

Co-production by people affected by cancer has been in all aspects of decision making throughout the MCIP programme of work. Using the experiences of people affected by cancer as video case studies has enabled us to share these in workshops, focus groups, clinical education and training sessions.

 Jonathan’s patient story http://youtu.be/mVXzDw883_c  Nina’s patient story http://youtu.be/-KptEpLqTKk  Loretta’s carers story http://youtu.be/eJQATvtOKd8  Shazia’s patient story http://youtu.be/9nh_EUw2pGQ

Sexual Orientation and the development of the Electronic Palliative Care Co-ordination System (EPaCCS) During the development of the above software programme, it was noted that the collection of sexual orientation data was not included in the system. EPaCCS enables the recording and sharing of people’s palliative care preferences and key details about their end of life care and will be used by GP practices and community services. Evidence and research was provided to demonstrate the need for this data to be collected and that knowing a person’s sexual orientation can impact on the decisions made around end of life care. The data collection was added into the system for a more inclusive approach to end of life care.

Shaping Futures with Looked After Children and Care Leavers We commissioned Chances in March to engage with Looked after Children and Care Leavers, aged sixteen plus, to better understand their experiences of using health, care, and education services. The project involved working in partnership with our city-wide safeguarding team, Manchester City Council, Chances, and the Manchester Metropolitan University. Young people from across Greater Manchester were invited to an event in November to share their experiences, listen to an inspirational speaker and engage with local services during a marketplace event. Duncan Craig, Survivors Manchester, was the inspirational speaker and provided an insight to his life, his work, and the struggles he has overcome to become Chief Executive of the organisation. Chances held interactive sessions with the young people and this information is currently being collated and analysed. Manchester City Council colleagues also held a focus group on educational services. An engagement report is due back to Manchester CCGs during January 2016. The report will influence training and education to GPs from our safeguarding team, as well as influence educational services across the city.

Informing the SEND local offer During the year, we engaged with parents and carers of children living with a disability to inform the development of the local health offer. We held information stalls and focus groups to understand the needs of parents and carers to help them care for, and support, young people living with disabilities. You can find out more about the Manchester Local Offer by visiting the Manchester City Council website http://manchester.fsd.org.uk/kb5/manchester/directory/directory.page?directorychannel=1-7

“We Care, Our Care” – Listening to carers Working in partnership with Manchester Carers Forum, a survey was carried out to better understand the needs of unpaid carers living in Manchester and using health services. Over 300 carers responded to the survey. Carers and members of our Patient and Public Advisory Groups analysed the information and produced a report on the findings.

The report was presented by Manchester Carers Forum to the three Manchester Clinical Commissioning Boards, where it was received positively. The findings have been used to inform the following areas of work:

 The development of a Manchester primary care standard for carers.  The development of a Macmillan Cancer Improvement Partnership information project for carers.  The development of awareness work with our GPs by our safeguarding teams about carers.  The development of the Living Longer, Living Better specification for domain 4 Team/Workforce, recognising carers as a key part of the workforce across the city of Manchester.  The Manchester City Council consultation on a carers’ strategy for Manchester.

This partnership work is continuing to highlight the needs of unpaid carers across the city and it will continue to be developed into the following year.

A copy of the report is available from the Communications and Engagement team by calling 0161 765 4004 or by emailing [email protected].

Healthier Together As part of the Healthier Together consultation, we held an information stall at an open day at Manchester People First. We used easy read versions of the consultation documents and response booklet to engage with, and listen to, service users. This provided an opportunity for people living with a learning disability to share what best care meant to them.

Making our CCGs websites more inclusive We have, this year, added BrowseAloud software to all of the Manchester CCGs websites. The software adds speech, reading and translation support to the website, facilitating access and participation for those people with print disabilities, dyslexia, low literacy, mild visual impairments, and those with English as a second language.

Shaping pregnancy and maternity services across Manchester We have been meeting with a group of women and their partners who wanted to share their concerns regarding maternity services in Manchester and who are advocating for more awareness of home births across the city. Listening to the voices of both women who have given birth and men who have supported their partners has provided an opportunity for the CCG to begin to develop a Maternity Services Liaison Committee. This work will continue into 2015/2016.

Supporting Manchester with Pride We worked in partnership with 11 NHS organisations across Greater Manchester and the LGBT Foundation to participate in Manchester Pride 2014.

Over 100 NHS staff took part in the Manchester Pride Parade and it led to the NHS walking entry winning the award of “Best Public Sector Service”.

Over 150 pieces of health information and resources were available on the health and wellbeing stall. Over 700 people visited the stall over four days. The opportunity was taken to engage with the Lesbian, Gay, Bisexual and Transgender community on the Healthier Together consultation, with over 180 consultation documents handed out. We also listened to experiences of using health services across Greater Manchester.

The experiences collated have been used to inform the further commissioning of the Pride in Practice scheme for GP practices in Manchester during 2014/2015. Pride in Practice is a quality assurance service that strengthens supports and develops the relationships with lesbian, gay and bisexual patients to ensure their needs are met effectively within their GP practice. This is a unique and targeted product from the LGBT Foundation they developed and implemented. Further information on Pride in Practice can be found here: http://lgbt.foundation/prideinpractice

The intelligence focused mainly on adults and we commissioned an engagement project with the Proud Trust (formerly known as LGBT Youth North West). The project is focusing on understanding the barriers and stigma for young people around mental health and sexual health across Manchester. Dr Vanessa Ray is undertaking research for the Proud Trust and we are expecting this in January 2016. The Proud Trust, with young people, is co-designing Trans awareness posters for young people to be displayed in GP practices across Manchester. Young women are also updating a guide to wellness and a guide to sex and relationships for young lesbian and bisexual women, which are to be launched as part of International Women’s Day in 2016. Our Senior Engagement Manager also participated in ‘A comprehensive service, available to all? ‘Healthcare for LGBT people’. This was an event hosted by the LGBT Foundation and was an opportunity to share on-going work around Pride in Practice, including the sexual orientation monitoring starting to take place in GP practices.

Mental Health Improvement Programme During 2014, we undertook a wide range of public engagement activities to inform our plans to improve mental health services across the city. The feedback we received—from service users, carers, staff, and the public—proved invaluable in designing the 17 service models required to provide people in Manchester with the mental health services they deserve. Alongside dedicated web pages and two online surveys, our engagement programme saw partners across the city working closely with us to ensure we involved as many people as possible and particularly those who these changes would affect most.

We worked with Macc to develop a 'facilitation offer', so local groups could work with independent local facilitators to plan, run, and report on over twenty bespoke engagement events. Twenty-two groups, which included 250 people, were engaged on a face-to-face basis with an external facilitator to listen to their feedback. We worked with Healthwatch Manchester and their volunteers to run awareness raising market stalls in partnership with the Manchester

Stop Smoking Service, who kindly let us use their existing stalls.

Macc also worked with independent patient and advocacy groups to research and develop a patients' charter reflecting the needs and wishes expressed by patients and carers in the city over recent years. We are currently supporting Macc to develop an independent mental health service user forum, called the Charter Alliance.

Over 1000 pieces of feedback were submitted by patients, carers, members of the public, and healthcare professionals working, and living, in Manchester. This information was assessed by an independent consultant who responded to it, in the engagement report below, through a series of “You said, We did” templates.

The feedback has informed the development of the 17 care pathways and addressed equality issues such as:

 Ensuring the personality disorder pathway is consistent for women who self-harm and widen the general criteria to permit a less restrictive approach.  Requirement to develop protocols for working with specialist substance misuse services for people, who live with mental health issues, who may be accessing the service with complex needs.  Amendment of the dementia pathway to ensure the reduction in anti-psychotic prescribing for dementia is a monitored outcome.  Inclusion in the overarching care planning specification that staff should be sensitive to cultural and community differences and the use of interpreters when required.  The development of a specific pathway for psychosexual services.  Inclusion in the psychotic crisis pathway the service must be willing to see people who are homeless in Manchester.  Providers will be required to monitor access to services according to sexual orientation as part of their contract.  Not specifying a lower age limit for younger people who use the dementia service pathway.  Inclusion in the overarching care planning specification on the roles of carers, family, and friends.

A copy of the report is available from the Communications and Engagement team by calling 0161 765 4004 or by emailing [email protected].

Understanding the impact on language barriers in accessing health services We commissioned, in March, Multi-Lingual Manchester at the University of Manchester to engage with Manchester residents to understand the effect language barriers may have on accessing health services. They were successful in gaining additional research funding to expand the research taking place. A series of interviews with patients, community groups, and practitioners has taken place and the qualitative data is currently being analysed. We have supported the project by facilitating access to GP practices and sharing existing quantitative data from various sources. An interim report is due in December 2016.

During 2014, Manchester CCGs became part of a partnership with Multi-Lingual Manchester, setting up a Language Forum. The forum enables issues, support, and best practice to be discussed and shared across the different communities in Manchester.

Reducing Isolation and Loneliness Grant funding programme Social isolation and loneliness has a serious negative impact on older people’s health and 37

wellbeing. Manchester CCGs invested in a grants programme to tackle this problem and awarded funding to 29 projects across Manchester providing social activities for people 50 years and over.

The projects offered a variety of activities, skills, and support from small neighbourhood projects to city wide projects across a number of themes, including: befriending and mentoring; community networking; education; food; cooking and nutrition; arts; fitness; mental health and wellbeing; environment; education; and volunteering. An independent evaluator has been appointed to work closely with the projects to gather evidence about what approaches are effective. You can read more information about the projects by visiting the Macc website. https://www.manchestercommunitycentral.org/reducing-social-isolation-and-loneliness-grant- fund-2014-2015

A programme of engagement is being delivered, alongside the projects, to increase communication and collaboration between NHS staff and the funded projects. There is a buddying system between the larger projects and the CCGs to build relationships as well as a number of events and activities to connect the small grant holders to staff and other stakeholders, including Age Friendly Manchester.

Always learning and future partnership working Manchester CCGs recognise the need to continue to learn, connect, and better understand the needs of people living in Manchester, especially for individuals and communities from protected characteristics and communities of interests.

We will continue to work in partnership with communities and our partners to ensure there is equality in the services we commission in Manchester.

We will continue to share best practice, guidance, and learning and work with our partners and stakeholders to tackle health inequalities across the city.

We will continue to co-produce innovative ways to engage and listen to individuals and communities.

Section Thirteen - Next steps

Corporate  Ensure successful implementation of the new internal EDHR Executive Steering Group.  Deliver a number of EDHR workshops for Small provider organisations.  Develop over-arching EDHR action plan to support key work streams and priorities.  Continue to deliver quarterly EA workshops and provide quality assurance to managers.  Identify EDS 2 goal and deliver external event for EDS 2 during 2016.  Collate all information from EDS 2 into the over-arching EDHR action plan.

Workforce  The organisations will continue to work towards developing inclusive organisations with systems, processes, polices and training in place to embed the principals of EDHR across the organisation, underpinned by a clear leadership and governance to set goals and priorities, review progress, and ensure continuous progress.  The organisations have invested in a joined in-house resource to lead on EDHR strategy, ensure the organisations remain legally compliant, and continue to develop best practices in working towards becoming an employer of choice.  The organisations are developing a more robust leadership and governance structure to set key priorities in line with the Locality Plan, to oversee progress on key programmes of work, and to facilitate continuous improvement.  A development programme for all employees at all levels is being developed and rolled out to promote understanding of EDHR and how the principals shape their role on a day- to-day basis, specifically around the design, procurement, and commissioning of services to meet the changing needs of the local population.  The organisations are developing and implementing an action plan for the EDHR strategy, focusing on the key priorities set by the EDHR Executive Steering Group.

Engagement activity  Commissioning Communities for All (C4ALL) to deliver a Safer Fasting Ramadan campaign with the Muslim community in North Manchester and engagement work with local communities to understand how patients feel about accessing primary and secondary health care. The focus on the engagement is to address the role of the community pharmacist and discussions around medication.  Commissioning Big Life Families to engage with young parents in Ardwick and Longsight and their understanding of using, and awareness, of local health services and identify what support is needed from GPs and community services.  Commissioning Big Life Families, Nestac, and Ward Co-ordination to deliver Female Genital Mutilation (FGM) Awareness training to frontline staff in Longsight and Wythenshawe. The engagement work has included inviting women to watch a National Theatre of Scotland production called “Rites”, which explores the practice of FGM through the real life stories of women affected by FGM and professionals that work trying to tackle the practice. Workshops were also commissioned from the Contact Theatre for women who attended the production and given the opportunity to share their experiences. An engagement project is to take place with the support group during the year.  Homeless and Health. An engagement project working in partnership with the Vallance Centre, Ardwick, Urban Village Medical Centre, Ancoats, and Inspire Manchester to understand the health and care needs of homeless people and their experiences.  Holding engagement sessions with people living with a learning disability, following quality concerns raised at a CCG Quality and Performance Committee.  Hold engagement sessions with the local Deaf Centre following concerns raised at the 39

EDS 2 event.

Section Fourteen – Appendices

Appendix A – Decision Making (Equality Analysis) http://www.centralmanchesterccg.nhs.uk/download.cfm?doc=docm93jijm4n3552.docx&ver=447 6

Appendix B - Performance Monitoring of Providers http://www.centralmanchesterccg.nhs.uk/download.cfm?doc=docm93jijm4n3553.docx&ver=447 8

Appendix C – Workforce data http://www.centralmanchesterccg.nhs.uk/download.cfm?doc=docm93jijm4n3554.docx&ver=447 9

Appendix D – EDS 2 Report 2015 http://www.centralmanchesterccg.nhs.uk/download.cfm?doc=docm93jijm4n3555.docx&ver=448 1

V.3 21st December 2015