Annual Public Sector Equality Duty Data Publication

Annual Public Sector Equality Duty Data Publication 31 Jan 2014

1 Contents Page

1. Introduction 2

2. Trafford Borough 2

3. Health and the Trafford Population 3

4. Commissioner Landscape 4

5. Equality Data 8

6. Equality Act 2010 8

7. Public Sector Duty 9

8. Human Rights 10

9. What this means for health care commissioning 11

10. EDHR Achievements. 12

11. Equality Objectives Working 13

12. Trafford Provider Equality Monitoring Data Schedule Returns 18

a. Central Manchester University Hospital NHS Foundation Trust ( Acute Provider) 19

b. University Hospital South Manchester NHS FT( Acute Provider) 26

c. Greater Manchester West Mental Health NHS FT (Mental Health Provider) 32

d. Pennine Care NHS FT Trafford Division (Community Services Provider) 37

13. TCCG Work Force Profile 45

14. Conclusion 48

2 1. Introduction

This document is the first annual public sector duty report for Trafford Clinical Commissioning Group (TCCG) . It has been complied by Greater Manchester Commissioning Support Unit to provide an overview of Equality Diversity and Human Rights work that has contributed and supported the delivery of continuous improvement required by the Equality Act 2010. Trafford Clinical Commissioning Group is a new NHS organisation, which was formed on 1st April 2013 when PCTs were abolished in England. Clinical Commissioning Groups took over some of the commissioning responsibilities from the former PCTs. TCCG buys, or commissions, health services for the people of Trafford and is responsible for making sure that people have the health services they need, that the services are safe and deliver high quality care. This is delivered within the budget allocated to us by a government agency called NHS England while making sure we take into account the different needs of all our diverse communities. At TCCG we are passionate about Equality Diversity and Human Rights and this is fully embedded in our values and ways of working. As commissioners of health services we aim to meet the health needs of our ever changing community whilst ensuring we consider and remove potential barriers and inequities faced by vulnerable groups.

2. Trafford Borough

Trafford was conceived as a metropolitan borough of Greater Manchester in 1974, with parts of its area bordering Manchester city centre and neighbouring Salford. Like the rest of the UK, Trafford’s population is growing and ageing. The resident population of Trafford is 230,000. Trafford is an area of 40 square miles, made up of 21 electoral wards, 63 councillors (3 members per ward) and has a population of broadly:

 49% of the population are male and 51% are female

 21.7% of the population are over 60

 19.6% of the population are from Black and Minority Ethnic groups

3  7.2% of the population were born outside of the European Union

 In 2001 the average life expectancy was 76.4 years for males and 80.3 years for females. Between 2008-2010 the average life expectancy increased to 79.2 for males and 83.4 for females

The borough has disparate socio-economic factors with some of the most affluent areas of the country situated alongside areas that are in the worst 5% nationally for deprivation. The population residing within Trafford’s boundaries is diverse, varying from areas of high deprivation in the north to areas of relative affluence in the south.

3. Health and the Trafford Population

The registered population of Trafford is 236,000. This represents all patients registered with a Trafford GP practice regardless of where they reside. The resident population of Trafford is 230,000. This represents all residents of Trafford regardless of who their GP practice is. The borough also has 37 GP practices, 33 dental practices, 62 pharmacies and 30 opticians. The number of households in Trafford is 94,500. 51% of Trafford residents consider their health to be “Very Good”.

Life expectancy in these areas varies greatly. A major challenge for improving the health of the borough lies in tackling the 80% of deaths in Trafford which are as a result of three types of disease: cardio-vascular disease (CVD), cancer and respiratory disease. This trend is consistent throughout the Trafford population and mortality rates for these disease areas are consistently above the national average.

Overall, the health of Trafford is better, or similar to, the national average. This ‘average’ picture however, can be misleading, particularly in Trafford when there are many lifestyle inequalities in relation to deprivation, gender and ethnicity. People in the more deprived parts of the borough live shorter lives than those in the more affluent areas – as

4 much as eleven years less for men and six years less for women, as indicated in the 2011 Health Profile for Trafford. Also, those with mental health problems and learning disabilities suffer much poorer physical health than the rest of the population. Importantly, there is a widely acknowledged recognition that healthcare costs relating to mental health are likely to double over the next 20 years.

In addition, life expectancy is increasing in men and women, although people are still dying earlier than necessary. Some specific health indicators in Trafford are significantly worse than the national average, including deaths caused by smoking, binge drinking in adults and the number of physically inactive children. The most economically and socially deprived neighbourhoods in Trafford have the greatest levels of health deprivation, with the worst being north of the borough within the ward of Clifford but also within pockets of Bucklow St-Martins and St Mary’s.

4. Commissioner Landscape Trafford is unusual in that its patients have access to multiple providers within the economy, rather than the usual 1:1 relationship between commissioners and providers. In health, the population of Trafford have choice in providers but the flow of patients is also influenced as to the location of where they live. Patients in South Trafford predominantly go to University Hospital of South Manchester (UHSM). Patients in the North access Central Manchester Foundation Trust (CMFT) both on their main site and the Trafford General Hospital (TGH) site. The TGH site is being developed in line with the Trafford New Health Deal. Trafford has developed an integrated care model which will continue to offer patients choice but the model will have a great emphasis on primary and community care; intervention and support.

Within Trafford there are three significant healthcare / hospital sites:

 Trafford General - where accident and emergency was based which now has a new Urgent Care Centre

 Altrincham General - which has a minor injuries unit (new build)

5  Stretford Memorial - which has outpatient services and a in-patient rehabilitation unit (new build) A large proportion of residents from the borough also receive care and treatment from the larger acute hospitals just over our borders at Central Manchester University Hospitals NHS Foundation Trust, Royal Manchester Children’s Hospital, University Hospital of South Manchester NHS Foundation Trust and Salford Royal NHS Foundation Trust, as well as specialist care from The Christie NHS Foundation Trust and others. Table 1: 2012-13 Activity by Provider (Trafford registered population) - Hospital Spells

Provider Spells % of Total Central Manchester (Trafford Site) 22,187 31% Central Manchester (Other Sites) 16,324 23% University Hospital of South Manchester 24,166 33% Salford Royal 5,439 8% Christie 1,247 2% GMW Mental Health 486 1% Pennine Acute 307 <1% Stockport 237 <1% All Other providers 1747 2% Total 72,140

Community Services Following Transforming Community Services, Trafford Primary Care Trust’s (PCT) decision was to not vertically integrate the Trafford Community Services with an acute trust, but rather to undertake a comprehensive procurement of all community services. Following completion of this process and contract award, from 1st April 2013, Pennine Care NHS Foundation Trust is responsible for the delivery of the majority of Trafford’s community services; which have remained

6 together as a Trafford Division within the Pennine Care organisation. Pennine Care also has experience of providing community services to other sectors within Greater Manchester.

Mental Health Trafford has over the past 7 years designed, developed and delivered an innovative approach to integrated care in mental health. Commissioning and provider organisations are now collaborating to provide integrated physical and mental health provision which spans historical organisational boundaries, whilst maximising the potential of joint working between secondary, primary and social care. The focus of the approach is to improve patient’s mental and physical health, continuing the reduced reliance on secondary and inpatient care where unnecessary and promoting primary and self-care.

Across the national mental health performance priorities, delivery of Improving Access to Psychological Therapies (IAPT) continues to be a challenge with increasing rises in referrals for both low and high intensity talking therapies support. However, the significant improvement in both access and recovery rates over the past 2 years suggest that further improvement is possible in terms of positive outcomes in terms of the defined national indicators such as provision of service against local prevalence rates for common mental health problems.

The impact of more people living into very old age has huge implications for mental health services in Trafford. As people get older, the likelihood of developing dementia increases. Local figures would seem to indicate that Trafford reflects the national situation, in that there are currently high numbers of people with dementia with unmet needs and remaining undiagnosed. Of those diagnosed, most people with dementia live at home, supported by neighbours, communities and mainstream services. Also, dementia patients are disproportionately represented in acute and residential care settings. One in four adult hospital beds is occupied by a patient with dementia. Two thirds of people with dementia live in the community. Two-thirds of all people living in care homes have a form of dementia, and the remaining third live in care homes and are usually at a more advanced stage of the illness.

7 As part of the systematic and integrated care strategy developments initiated in Trafford in line with the Health and Well Being Strategy, we expect to clearly improve the experience and outcomes for those with and without mental health problems (and their carers) and would also reduce emergency admissions, re-admissions and length of stay, especially in over 65s, and delay or reduce admissions into residential care through the RAID programme.

The majority of mental health issues are dealt with and managed at primary care level, by GPs, who respond with a range of strategies to deal with the 90% of common mental health problems such as anxiety, depression and post-traumatic stress reactions.

A comprehensive range of specialist Community Mental Health Services are commissioned in line with the responsible commissioner guidance whereby for the majority of those registered with Trafford GPs who reside in Trafford – services are commissioned from Greater Manchester West NHS Foundation Trust (currently the best performing Mental Health trust in the North of England) and for those resident in Manchester from Manchester Mental Health and Community NHS Trust, and where necessary additional services are secured from other specialist service providers in the North West (e.g. Learning Disability and Community Eating Disorders services are commissioned from Cheshire and Wirral Partnership NHS Foundation Trust).

Trafford patients are also able to access a wide range of support from jointly commissioned health and social care services targeting common mental health difficulties through a number of third sector organisations (including BlueSCI, Self Help Services, Age UK, Carers Centre, 42nd Street, Relate and Trafford Rape Crisis). These are important partnerships that enable preventative and effective support for a range of difficulties (such as coping with depression, anxiety management, alcohol and substance misuse problems, enhancing self esteem, stress management, assertiveness development, anger management, obesity, coping with loss and bereavement, managing pain and carer

8 support programmes) and work to reduce stigma and strengthen the emotional health and well being of the Trafford population.

5. Equality Data

The equality data included within this report refers largely to secondary care equality data from TCCG main providers of acute, community and mental health providers of Trafford health care services. The evidence represents a snap shot of data that has been scrutinised to provide assurance to TCCG of providers legal compliance with the Equality Act 2010 public sector equality duties and provider performance against the contractual equality requirements . TCCG have included a detailed equality monitoring schedule within all its major provider contracts. The monitoring schedule is used to regularly assess provider performance against the requirements of the Equality Act 2010 and forms a significant part of the reporting within this document. Each of the main providers have the responsibility to produce an annual public sector duty annual report, which will have additional information found on each of the providers web sites under each organisations own annual publication by the 31st January 2014.

TCCG is no longer responsible for the reporting of primary care data e.g. GP Practice patient data summary reporting. Most of primary care equality diversity and human rights (EDHR) legal assurance reporting is now under the responsibility of NHS England following the April 2013 re-structure of NHS services.

6. Equality Act 2010

The Equality Act (2010) is the UK’s discrimination law, which protects individuals from unfair treatment and promotes a fairer and equal society. It protects people from discrimination, harassment and victimisation in work, education and when accessing services like healthcare.

The Equality Act protects anyone who falls into a ‘protected characteristic’.

9  age,

 disability,

 gender reassignment,

 marriage and civil partnership,

 pregnancy and maternity  race,

 religion or belief,

 sex,

 sexual orientation

7. The Public Sector Duty

The General Duty ensures that Public Bodies such as TCCG in the exercise of their functions, have due regard to the need to:

 Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. (This involves removing or minimising disadvantages suffered by people due to their protected characteristics.)

 Advance equality of opportunity between people who share a protected characteristic and those who do not. ( Which involves meeting the needs of people with protected characteristics and encourage people with protected characteristics to participate in public life or in other activities where their participation is low.)

 Foster good relations between people who share a protected characteristic and those who do not.(Involves tackling prejudice and promoting understanding between people who share a protected characteristic and others.)

The Specific Duties

10 In addition to the general duties, public sector organisations have specific duties to fulfil which are legal requirements that ensure the delivery of the general duty. Under the DoH revised timeframes for reporting of these duties CCGs are required to publish in a manner that is accessible to the public the following:  Information to demonstrate its compliance with the public sector Equality Duty at least annually, starting by 31 January 2014. This information must include, in particular, information relating to people who share a protected characteristic who are  its employees – (public authorities with fewer than 150 employees are exempt) and  people affected by its policies and practices.  Equality objectives at least every four years starting by 13 October 2013. All such objectives must be specific and measurable.

Having due regard means consciously thinking about the three aims of the Equality Duty as part of the process of decision-making. This means that consideration of equality issues must influence the decisions reached by public bodies for example how they act as employers; how they develop, evaluate and review policy; how they design, deliver and evaluate services, and how they commission and procure from others.

8. Human Rights

TCCG is fully committed to working with members of the public, patients, carers and partners to build a culture through which we treat everyone with fairness, respect, equality and dignity, and respect their autonomy (the FREDA principles).

We ensure that our Human Resources policies including recruitment policies, exit interviews and restructures are fair and transparent and take account of reasonable adjustments, engagement with staff and any adverse impacts upon local protected groups resulting from key changes or reviews. We also regularly review complaints/PALS issues, patient stories

11 and Serious Untoward Interviews to ensure that no breaches of Human rights have occurred; we also ensure that these are scrutinised for discrimination by protected characteristic (including violent discrimination or hate crime) and that we have procedures in place to record and report such discrimination through our quality governance structures. Human Rights will be an additional reporting requirements which has been built into the commissioning intentions of the CCG. We will be focusing on improving Human Rights working and reporting in 2014.

9. What this means for health care commissioning We aim to commission services that give all our vulnerable groups the same opportunities to access healthcare as the general population and to have the same health outcomes. This means that we pay due regard to:  Reducing inequalities in health outcomes and experience between patients. We do this by planning our strategic aims and working in partnership with Trafford Council, our health care providers and others to address the needs of vulnerable groups as shown in the JSNA.  Removing any barriers or inequalities faced by more vulnerable protected groups in accessing healthcare.  Removing or minimising disadvantages suffered by people due to their protected characteristics.  Encouraging people who are less likely to access our services to use them  Promoting the involvement of patients and their carers in decisions about provision of the health services to them  Enabling patients to make choices with respect to aspects of health services provided to them

The need to make “reasonable adjustments” is an anticipatory duty – in other words, we need to find out what the barriers for protected groups might be in advance (as far as possible) and put arrangements in place to remove them. One way of doing this is by Equality Analysis delivered by both members of TCCG staff and through GM CSU commissioned services.

12 We must also set Equality Objectives once every 4 years, and collect annual equality data in relation to workforce and service delivery issues. We also need to highlight any significant data areas for improvement, with links to improvement plans. We need to do this so we can target resources where they will make the most difference.

10.EDHR Achievements.

TCCG has with its key partners and local stakeholders been working to fully embed Equality Diversity and Human Rights into its core business processes and is developing a whole system multi sector approach. Much of the work undertaken in the early period of the TCCG as new health commissioning organisation within a new health system has been to review, evaluate and develop a bedrock for continuous sustainable EDHR working. Part of the challenge of this significant change period through the transition and implementation of the Health and Social Care Act 2012, has been to maintain the EDHR focus as key necessity in health care commissioning and provision. A significant part of the continuation of maintaining the TCCG EDHR focus has been to address a long standing traditional legacy, historical views and lack of high quality performance across the wider health system in both commissioning and providers organisations.

TCCG recognises the need to build on its existing best practice whilst taking the opportunity to forge new innovative ways of working to ensure that long standing EDHR development issues for example EDHR data quality improvement can benefit from enhanced matrix working with key providers and stakeholders. TCCG has been building its EDHR infrastructure and enhancing its partnership relationship to established improved systems of reporting, monitoring and driving high quality continuous improvement that will ultimately lead to improved health outcomes and reduced health inequalities for the whole Trafford Borough community.

Through the challenges of this significant change period TCCG has been working to ensure that its embedded whole system EDHR methodology is fit for purpose in achieving its strategic goals as outlined in its Operational Plans and

13 strategic goals and objectives. This ongoing development work has ensured that the TCCG continues to utilise the requirements of the Equality Act 2010 not only to ensure legal compliance, but to also to drive continuous improvement, focus renewed energy in the commissioning of health services, leading to the best possible healthcare outcomes through the commissioning of high quality, fair and integrated services of all the Trafford borough residents.

TCCG produced its pre- authorisation EDHR strategy and action plan in February 2013. The strategy action plan was developed to ensure that EDHR working was embedded within TCCG for the first 12 months of the CCG. TCCG has commissioned GM CSU Equality, Diversity and Human Rights Service which provide TCCG with subject matter expertise via dedicated EDHR consultants. The EDHR service ensures a level of compliance including the following four co – dependent sub-services:

a) Specialist Strategic & Operational EDHR Advice & Support b) Management of 4 yearly Equality Objectives & Annual Action Plans c) Annual Sector Equality Duty- Annual Equality Publication d) Annual Submission to NHS Equality Delivery System (EDS)

GM CSU has developed and is implementing the Equality Diversity Human Rights Model of excellence which will ensure that EDHR is fully embedded into all ways of CM CSU working and is built into every service commissioned by TCCG.

11.Equality Objectives Working

TCCG Equality Objectives are;

 Objective 1. Improve equality data collection, analysis, and usage to inform commissioning decisions and improve health inequalities for all protected groups.

 Objective 2. Ensure ongoing effective senior leadership and awareness of equality agenda for TCCG’s and their membership practices.

14  Objective 3. Patient and public communication & engagement is inclusive of people from all protected groups. Equality Objectives Achievements

Objective 1. Improve equality data collection, analysis, and usage to inform commissioning decisions and improve health inequalities for all protected groups. TCCG recognise the importance of having a robust up to date EDHR evidence base that informs commissioning decisions and underpins the commissioning cycle. Equality data collection and utilisation continuous to be a challenging area for many organisation within the NHS and continues to be a priority development area of work within Trafford.

Equality Objective key achievements;

 All major provider contracts have a detailed equality monitoring schedule which requires detailed reports to be made to TCCG as part of contract quality reporting. GM CSU EDHR consultant and the Quality performance team have been working more closely to support providers, to ensure clarity about the schedule requirements, and provide direct collaborative support. This has approach has resulted in; o a more enhanced scrutiny of provider performance, o sharing of supportive subject matter expertise in EDHR, o sharing of best practice between providers, o improved detailed gap analysis of EDHR performance, o improved SMART EDHR action plans, o shared innovative new ways of working,

15 o and improved EDHR quality returns. GM CSU EDHR team have established a GM provider group to explore and agree innovative ways of working in EDHR reporting and drive quality within providers.

 TCCG has commissioned management services from Greater Manchester Commissioning Service Unit including the EDHR service which provides subject matter expertise and supports TCCG in legal compliance, additionally within GM CSU the EDHR Model of Excellence ensures that EDHR is embedded into all GM CSU services commissioned by TCCG. This has led to improved matrix working of business intelligence, contracts, commissioning and performance.

 TCCG commissioning team have been trained and adopted the GM CSU new Equality Analysis tools which replaces the traditional equality impact assessment tools. Equality Analysis of all commissioning decisions are taking place improving EDHR data utilisation and enhancing EDHR capacity with TCCG staff.

 The GM CSU Business Intelligence team have reviewed all data sharing agreements and have reviewed data requirements for commissioners from providers data. A new GM wide information schedule is to be included in the contracts for 2014/15 is being developed which will include the EDHR monitoring schedule data requirements. This will lead to enhanced automated quarterly reporting.

 JSNA EDHR data has been reviewed TCCG will be working with the local authority to identify improvements in the data quality.

16  TCCG has signed up and has been implementing EDS1 and is working towards delivering EDS2 a timetable for delivery has been developed with stakeholder engagement events to take place in February 2014 and a positions statement of achievement to published in April 2014. EDS has been written into all main provider contracts and is being reported on via the EDHR monitoring schedule.

Objective 2. Ensure ongoing effective senior leadership and awareness of equality agenda for TCCG’s and their membership practices.

 The TCCG Governing Body has had briefings and EDHR awareness sessions to ensure Governing Body members have to support improved understanding in regards to EDHR and their roles as senior leaders. The aim of this support has been to enhance the Governing Body members capacity confidence and commitment to the EDHR agenda. Future in-depth training sessions are being reviewed as part of the TCCG organisation development plan. This has lead to renewed focus and enhanced understanding and ownership of the EDHR agenda at the senior levels of the CCG.

 A senior executive EDHR lead has been identified with overall reporting responsibility.

 EDHR champions from the commissioning team have been identified to ensure that EDHR is owned and implemented through the senior management structure.

 Governance performance and reporting systems have EDHR built into them with regular reporting to them Management Team and the Governing Body. Governance policies have been reviewed for EDHR implications and EDHR recommendations have been implemented.

17  All decision making and senior management ratification requires an equality analysis to be completed.

Objective 3. Patient and public communication & engagement is inclusive of people from all protected groups.

 TCCG engagement team is supporting engagement activity within CCG and has included monitoring of protected characteristics groups to ensure engagement activity all groups where relevant are appropriately represented in the TCCG’s patient and public involvement framework. Engagement monitoring is reported via the annual report .

 There has been a particular focus on engaging with the third sector as this has been an area emphasised needing stronger involvement in the commissioning cycle.

 EDHR has been a priority in building rapport to get local groups involved in our Equality Delivery System including

o Health watch

o Local Authority

o Various organisations in support of the third sector work

o Focus groups looking at specific areas or work streams which may involve their service users,

o Other organisations and/or members of the community which have an interest in the chosen topic,

o Local charities

18 o and local patient participation groups.

 TCCG engagement team has been sharing information with the community raising awareness about TCCG activity, building a presence and promoting various work streams of the CCG to the local community (for example the new health deal), as well as collating intelligence around local health concerns which I have been able to feed back to commissioners.

 The communication and engagement team have developed a Better engagement, better communications, better health Integrated communications and engagement strategy for Trafford Clinical Commissioning Group October 2013 and have a work plan in place. To ensure the CCG captures more in depth engagement work, projects and outcomes the engagement team have produced a ‘communication and engagement log’. The log will also help evidence and enhance communication of engagement activity within the CCG. Regular monthly departmental engagement review meetings are also held to raise awareness of engagement activity and to support TCCG departments co ordination of engagement activity.

12.Trafford Provider Equality Monitoring Data Schedule Returns

The focus of this work has been to secure improved reporting from the major TCCG providers of acute, community and mental health services. The contractual equality monitoring schedule has been developed and implemented to ensure that as commissioners TCCG is championing and driving the Equality Act 2010 outcomes of equity and fairness in health care service provision and implementation. The following section contains summaries of the major TCCG providers data returns against the contract equality monitoring schedule contained within all TCCG major provider contracts. The

19 evidence presented here is to provide an audit of baseline data against the schedule and the nine protected characteristics groups of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race/ethnicity, sex (gender), sexual orientation and religion or belief.

The requested evidence from providers was for the period of April to September 2013 to provide a snap shot of data. Some providers were not able to present a full report from this period as this work was yet to be completed. In this case additional assurance was secured from providers to ensure that by the 31st January 2014 the providers will publish full returns to TCCG or provide detail improvement action plans. All evidence and assurances have been scrutinised to ensure TCCG of provider’s legal compliance with the public sector equality duties and EDHR provider performance against the schedule criteria. It should be noted that each of the providers have the same requirements as TCCG to publish information to demonstrate compliance against the Equality Act 2010. These provider publications will be located on each organisations own website.

The provider EDHR data returns have been surmised in tables below, which indicate what data has been submitted, provide a RAG rating of the quality of the data and indicate which of the nine protected characteristic groups are covered against each of the schedule criteria.

Evidence presented with indication of protected groups. No evidence improvement actions plans in place or pending. daaa No evidence or action plans in place.

Central Manchester University Hospital NHS Foundation Trust ( Acute Provider Trafford)

20 Topic Reporting Elements RAG Submission and Current Position

1. Workforce Breakdown by protected characteristics* Workforce Profile 2012/13 Ethnicity, Gender, Age, disability, Religion or Belief, Sexual Orientation  Staff by banding  Recruitment - applications, short-listing and ▪ Training Data Ethnicity, Gender, Age, Disability, appointments Religion or Belief, Sexual Orientation  Training  Grievances ▪ Sick Leave Ethnicity, Gender, Age, Disability,  Sick leave Religion or Belief, Sexual Orientation  Disciplinaries  Bullying and Harassment Employment Tribunals (discrimination related) ▪ Employment Tribunals Equality Data Ethnicity,  Leavers headcount Gender, Age, disability, Religion or Belief, Sexual  summary of relevant issues from exit Orientation interviews The Trust is currently reviewing the exit interview questionnaire to capture E & D related issues. Our aspiration is to provide this information at the end of 2013/14.

 Staff survey outcomes Staff Survey outcomes 2011 & 2012 Additional Theme: Equality & Diversity KF (26/27/28) No protected characteristic data available.

 Staff network update . Black and Minority Ethnic (BME) . Lesbian, Gay, Bisexual and Transgender (LGBT) . Disabled  Board composition by protected Board Workforce Profile 2012/13 Ethnicity, Gender, characteristics (Age, Disability, race, Age, disability, Religion or Belief, Sexual Orientation religion or belief, sex and sexual orientation)

2.Service Use / Completed initial audit for equality monitoring data The Trust has completed its Annual Patient Profile for Data sets and by protected characteristics of patients. 2012/13. The data is limited by the ability of the Completion Trust’s PAS to collect a limited range of protected Rate Equality monitoring data improvement targets by characteristics (Age, Gender, Ethnic Origin, Religion). The Trust is considering how this can be addressed.

21 protected characteristics for patients

Progress against monitoring data improvement The Trust has also produced a patient profiling report targets by protected characteristics for patients for the first six month of this operational year. Patient profile data provided for out patients, in patients Audit of DNA rates by protected groups accident and emergency includes Age, Gender, Ethnic Origin, Religion.

Progress against monitoring data improvement targets by protected characteristics for patients will be included in future patient profiling reports.

The Trust Equality, Diversity and Human Rights Strategic Framework 2010-2015 contains our current agreed equality objectives which have been amended and updated to reflect progress and our identified priorities for equality and diversity over the coming 12 months.

The Trust will be updating its Equality Objectives 2010 – 2015 following :

 the publication of the second version of the Equality Delivery System.  the external verification of the Trust's self- assessment of its performance against the current version of the Equality Delivery System.  The Trust has had time to consider the implications of the revised Public Sector Equality Duty

Until this happens, the Trust will be working towards implementing its current objectives.

Further details are available on the Trust website: http://www.cmft.nhs.uk/equality-and- diversity/published-equality-objectives

22 The current reports do not include DNA information as the information is not currently available.

3. Accessibility ▪ Report disability access audit The Trust has completed a site wide access audit of all of its services completed by a specialist contractor a robust action plan has been completed and is regularly updated and reviewed.

Access audit summary provided.

http://cmft.directenquiries.com/information/Central %20Manchester%20University %20Hospitals/448635/summary/information.aspx

▪ Physical access by department As above

▪ Signage and accessibility As above

▪ Availability of Prayer facilities (where appropriate) The Trust has a Multi-Faith Centre catering for all faiths (including people of no faith). There are also two multi-faith/quite rooms in the new hospital development. A flyer and programme of the Multi- faith Annual Event is attached.

▪ Availability of Halal / Kosher meals for patients and The Trust has a multi-cultural menu available to staff (where applicable) patients. This includes the offer of Halal and Kosher food. A Shabbos kitchen is also available for patients and families which is stocked on a daily basis. A kosher and halal sample menu provided. .

▪ Use of Interpretation & Translation (including The Trust has a dedicated ITS service and related PALS and Significant events reports) framework contract arrangement through this it conducts more that £1M interpreting sessions each year. Any issues raised via complaints or incidents are investigated in line with policy.

Details of the Translation service available is accessible on our external web pages on the

23 following link

http://www.cmft.nhs.uk/information-for-patients- visitors-and-carers/patient-advice-and- support/interpretation-and-translation-service

4. Patient ▪ Complaints: Statistics on number of complaints by Whilst there is currently a robust quality assurance Experience & equality issues, location, brief outline and details of process for dealing with complaints, a process for Complaints ** resolution. collection of equality monitoring data is being developed.

A data quality review is underway at an early stage but an improvement plan will be developed.

▪ Complainant: Statistics on number of complaints As above broken down by Equality group of complainant and a correlation of these.

▪ Summary of actions/lessons learnt in addressing Patient profiling data in relation to patient experience EDHR related complaints is currently collected.

The data is currently being analysed and it intended that Trust will be able to report on trends within the next 6 months.

▪ Patient experience: Breakdown of satisfaction Whilst there is currently a robust quality assurance levels in patient experience surveys by protected process for dealing with complaints, a process for characteristics of patients collection of equality monitoring data is being developed.

A data quality review is underway at an early stage but an improvement plan will be developed.

5.Communicati  Consultations with equality groups The Trust held its first Equality and Diversity Fortnight ons &  Targeted communications in May 2013. The Trust also has an on going Engagement  Equality events programme of equality events.

Details relating to Staff communication and Engagement activity provided

24 6. Management  Numbers attending EIA training The Trust has completed 184 initial equality impact  EIAs completed and published assessments from April to September 2013.  E&D training by % of workforce achieving Trusts specific KSF levels of competency The Trust is currently reviewing its Equality Impact  Access to training by protected Assessment Framework and as a result EqIA training characteristics of staff has been suspended pending completion of this  Breakdown of staff undertaking PDR by protected characteristic review. The Trust no longer use the KSF framework as the organisation introduced a new appraisal system. Compliance for completion of Appraisals is monitored on a monthly basis in the Operational Management Group (OMG) Reports and Divisions are expected to reach 100% on an on-going monthly basis. This is closely monitored by Divisions, HR Managers and Operational Management Group (OMG).

The Trust is working our Workforce PDR Information department to find a resolution for the need to report on this aspect of the schedule

7.Sub-  Where other organisations are used to carry This is a core component of our procurement contracting out work, outline of the equality clauses or process. criteria for selection included in contracts / tender specifications 8.Equality  National Performance Framework EDS The Trust has completed an internal assessment and Delivery action plan and equality objectives. verification of its performance against the 18 EDS System (EDS) Outcomes. A progress report has been submitted to Equality Act the Equality Implementation Group. 2010 Objectives The Trust is developing robust arrangements for the external verification of it EDS Assessment. A report has been submitted to the Equality Implementation Group for onwards transmission to the Trust Board.

Issues to Any problems to be reported to the PCT which affect No evidence presented. Report communities access to appropriate and responsive services e.g. GP lack of details on GP referral forms such as communication requirements causing operations to be delayed as not notified that consent

25 forms needed to be translated into Braille

CMFT Summary

CMFT have significant resource in governance & Infrastructure devoted to EDHR delivery. Central to this is the Equality Implementation Group formed in 2012. The Group is chaired by a Trust Director with membership including a Non- Executive Director, Trust Governor representative and senior managers. Membership also includes Equality & Diversity specialists, staff side and Sodexo. The Group’s central remit is to oversee the Trust’s Equality & Diversity agenda & to provide assurance to the Board. The operational delivery of the Equality & Diversity agenda is supported by :

 The Service Equality Team – E&D specialists  The Human Resources Directorate - E&D specialist  Equality & Diversity Co-ordinators – Trust managers and senior staff representing each clinical Division and Corporate Services  E&D Staff Networks (BME, Disability and LGBT)

By working closely together, these groups are working towards delivering the E&D agenda along with Trust Managers and staff with the ultimate aim of mainstreaming the agenda.

A summary of the previous year’s activities is available in the Trust’s Annual Report (2012 – 13) on pages 14 to 16 or via this link - http://www.cmft.nhs.uk/media/709404/central%20summary%20annual%20report%202013.pdf

CMFT have provided significant data that demonstrates robust compliance with the Equality Act 2010 and the PSED. Performance against the schedule is robust with good levels of evidence provided. There are several areas identified for improvements in data quality;

26  increasing the numbers of protected characteristic groups overall where relevant,

 developing SMART action plans to cover all indentified gaps in evidence and data quality improvement,

 produce more Trafford specific data against the schedule criteria,

 produce equality monitoring data improvement targets by protected characteristics for patients and progress reports against monitoring data improvement targets by protected characteristics for patients

 Improve evidencing of EDHR data utilisation to demonstrate and evidence improvements in patients access, experience and outcomes.

University Hospital South Manchester NHS FT( Acute Provider TCCG)

Topic Reporting Elements RAG Submission and Current Position

1. Workforce Breakdown by protected characteristics* Workforce monitoring data Age, disability, ethnicity, gender, marital status, maternity, religious  Staff by banding belief, sexual orientation.  Recruitment - applications, short-listing and appointments Recruitment data June- Oct 2013 Age, disability,  Training ethnicity, gender, gender reassignment marital  Grievances status, religion, sexual orientation.  Sick leave  Disciplinaries Workforce data Annual Report, 2012-2013  Bullying and Harassment Employment Tribunals (discrimination related) contains age, disability, ethnicity, gender.  Leavers headcount UHSM Application form  summary of relevant issues from exit interviews People OD Strategy 2013 2015 No specific reference to EDHR

Training –all mandatory training modules recorded on ESR no data provided.

27 We do not currently collect information relating to Gender re-assignment, civil partnership

Disclosure rates are low for protected characteristics = Disability, Sexual orientation

The Trust does not routinely complete Exit Interviews and analyse the data

 Staff survey outcomes Staff Survey 2012 Age, disability, ethnicity, gender, marital status, maternity, religious belief, sexual orientation. (The 2013 staff survey is currently being conducted and is not available at the time of writing this report.)

 Staff network update UHSM do not currently have any formal staff networks in place across the Trust based on Equality and Diversity issues.  Board composition by protected Data is included within the workforce data characteristics (Age, Disability, race, religion or belief, sex and sexual orientation)

2.Service Use / Completed initial audit for equality monitoring data Equality and Diversity Data relating to Patients Data sets and by protected characteristics of patients. for the period April – September 2013 (Information Completion retrieved via PAZ) Inpatient & Outpatient data ethnicity, marriage & civil partnership only. Rate Equality monitoring data improvement targets by protected characteristics for patients A&E ethnicity data only. No Trafford CCG specific Progress against monitoring data improvement data. targets by protected characteristics for patients No equality monitoring data improvement targets by Audit of DNA rates by protected groups protected characteristics for patients Audit of DNA rates by protected groups pending.

3. Accessibility ▪ Report disability access audit From an estates perspective, the Trust does not undertake a regular 6 monthly disability access audit but, instead, relies upon information from different sources such as asset condition surveys

28 and specific project driven assessments to demonstrate compliance with prevailing regulations.

The Trust has invested considerably in improving access to its buildings for disabled users.

A full disability access audit also extends to examining the use and management of buildings and the concept of making reasonable adjustments which may be non-building related and hence informed by management and clinical practices.

▪ Signage and accessibility Trust signage provision is considered as good. Regular reviews of signage are undertaken through the estates sub-group in order to improve way- finding.

Signage is supplemented by a number of volunteers who help direct people to their destination.

▪ Availability of Prayer facilities (where appropriate) The hospital Chaplaincy team is a multi-faith team. The hospital chapel is open 24 hours a day for anyone to use. The hospital also has prayer / quiet rooms available. There are regular services and the times are displayed on the wards. The chaplains have a selection of holy books that can be borrowed. The multi faith prayer room is situated at the main entrance and is open to everyone, with or without faith. Information relating to these services are included in patients welcome packs

Further information about the services available by

29 the chaplaincy team can be found on the following link

http://www.uhsm.nhs.uk/patients/Pages/Chaplaincy.a spx

▪ Availability of Halal / Kosher meals for patients and Halal and Kosher meals are readily available for staff (where applicable) patients. The Trust scores above the national average in terms of its PLACE assessment for food.

▪ Use of Interpretation & Translation (including Details of the Translation service available is related PALS and Significant events reports) accessible on our external web pages on the following link

http://www.uhsm.nhs.uk/patients/Pages/its.aspx

No usage data provided.

4. Patient ▪ Complaints: Statistics on number of complaints by Equality Monitoring form sent with all formal Experience & equality issues, location, brief outline and details of complaints. Data available on Equality and Diversity Complaints ** resolution. re complaints.

Reported formally via Patient experience report quarterly. No reports provided, reports pending.

▪ Complainant: Statistics on number of complaints Data collected on Safeguard database KO41 broken down by Equality group of complainant and a statistics collected and reported annually. Data correlation of these. available on complainant ED issues.

Reported in the patient experience report and the annual complaint report. No reports provided, reports pending.

30 ▪ Summary of actions/lessons learnt in addressing Reported in the patient experience report and the EDHR related complaints annual complaint report. No reports provided, reports pending.

▪ Patient experience: Breakdown of satisfaction Review all national surveys in relation to E&D data. levels in patient experience surveys by protected Review all internal forms of patient and carer characteristics of patients feedback re E&D issues.

Patient Experience report. No reports provided, reports pending.

5.Communicati  Consultations with equality groups Activity in this area in not currently collated and ons &  Targeted communications reported on centrally however examples of this can Engagement  Equality events be found on our website eg Asian Breast Cancer support group

http://www.uhsm.nhs.uk/research/Pages/abcgroup.as px

6. Management  Numbers attending EIA training UHSM do not routinely provide EIA training or keep a  EIAs completed and published central record of competed EIA’s however the need  E&D training by % of workforce achieving to complete an EIA is a requirement of all new Trusts specific KSF levels of competency policies being completed ref ‘Policy on policies’. All  Access to training by protected characteristics of staff policy documents including the EIA are published  Breakdown of staff undertaking PDR by internally protected characteristic UHSM do not use the KSF framework and so are unable to report on this area

Do not currently record E&D training on OLM within ESR and are therefore unable to report in this area. A e-learning package for E&D is being developed for delivery to all staff.

31 7.Sub-  Where other organisations are used to carry Tender procurement questions provided, no contract contracting out work, outline of the equality clauses or clause provided. criteria for selection included in contracts / tender specifications 8.Equality  National Performance Framework EDS UHSM has signed up to EDS2 and is developing Delivery action plan and equality objectives. action plans for implementation System (EDS) Equality Act Equality objectives are up to date and located on 2010 Objectives UHSM website. http://www.uhsm.nhs.uk/patients/ed/Pages/home. aspx

Issues to Any problems to be reported to the PCT which affect No evidence presented. Report communities access to appropriate and responsive services e.g. GP lack of details on GP referral forms such as communication requirements causing operations to be delayed as not notified that consent forms needed to be translated into Braille

Summary

Currently UHSM is progressing significant amounts of change working with the arrival of a new Chief Executive. UHSM is committed to addressing these and the other improvements required and will now be refocusing a key team on delivering against these improvements. At the present time UHSM do not have a dedicated resource for Equality and Diversity this is also being reviewed.

UHSM has provided evidence against the schedule which demonstrates legal compliance with the Equality Act 2010. Although significant amounts of evidence was presented much of the data proved to be generic data and not particular to TCCG. This is an important area for improvement for future performance and quality reporting against the EDHR

32 schedule. UHSM has recently signed up to and is committed to implementing the Equality Delivery System 2, this will be an important element in securing the enhancement of UHSM Equality Diversity and Human Rights performance.

There are several areas identified for improvements in evidence that relate to data quality;

 provide EDS2 implementation plan,

 adopt and implement equality analysis also known as equality impact assessment,

 increasing the numbers of protected characteristic groups monitoring overall where relevant,

 improve equality monitoring of patients and provide Trafford specific patient profiles by the protected characteristics groups,

 produce more Trafford specific data against the schedule criteria,

 developing SMART action plans to cover all indentified gaps in evidence and data quality improvements,

 Improve evidencing of EDHR data utilisation to demonstrate and evidence improvements in patients access, experience and outcomes by the protected characteristics groups,

Greater Manchester West Mental Health NHS FT (TCCG mental health provider)

1. Workforce Breakdown by protected characteristics* GMW Trafford Directorate workforce data.

 Staff by banding Workforce monitoring data Age, disability,

33  Recruitment - applications, short-listing and ethnicity, gender, marital status, religious belief, appointments sexual orientation.  Training  Grievances Pay Band, ethnicity and gender.  Sick leave  Disciplinaries Recruitment data June, ethnicity and gender.  Bullying and Harassment Employment Tribunals (discrimination related) Grievances age, disability, ethnicity, gender.  Leavers headcount  summary of relevant issues from exit Disciplinaries age, disability, ethnicity, gender. interviews Bullying and Harassment age, disability, ethnicity, gender.

Leavers headcount age, disability, ethnicity, gender. http://www.gmw.nhs.uk/equality-and-diversity

 Staff survey outcomes Staff Survey outcomes age, disability, ethnicity, gender.

Key findings for gender, disability and race

 Staff network update Greater Manchester West Mental Health NHS Foundation Trust October 2012 – September 2013 Equality, Diversity and Human Right Schedule Report page 58 The Trust will be conducting a recruitment drive for Equality Champions in December 2013, with a view for them to start attending the Trust’s Equality Diversity and Recovery Steering Group in the New Year.

 Board composition by protected Board Workforce Profile 2012/13, Age, Ethnicity characteristics (Age, Disability, race, Disability, Gender, Religion or Belief, Sexual religion or belief, sex and sexual orientation) Orientation.

2.Service Use / Completed initial audit for equality monitoring data Data until September 2013. Data sets and by protected characteristics of patients. Completion GMW Trafford Directorate data Age, gender,

34 Rate Equality monitoring data improvement targets by ethnicity, disability, sexual orientation. protected characteristics for patients Alcohol and Drug Age, gender, ethnicity, disability Progress against monitoring data improvement all areas. targets by protected characteristics for patients Adult Forensic Service Directorate Age, gender, Audit of DNA rates by protected groups ethnicity, disability all areas.

Adult & Youth Specialised Service, Age, gender, ethnicity, disability all areas.

The Trust has not identified equality monitoring improvement targets by protected characteristic during the specified time period. 3. Accessibility ▪ Report disability access audit Section 4 of report. The Trust has a DDA group which meets quarterly where updates on works being undertaken are provided to service reps.

Each year the Estates and Facilities team produces a draft statutory compliance programme of works for approval at the Capital Implementation Group and further Board approval as part of the capital programme.

The Quality Account reports that our on-going programme of capital investment in our estate has delivered £12m of quality improvements in 2012/13.

▪ Availability of Prayer facilities (where appropriate) The Trust has a Multi-Faith rooms across each of its sites including Trafford Moorside Unit.

▪ Availability of Halal / Kosher meals for patients and The Trust has a multi-cultural menu available to staff (where applicable) patients. This includes the offer of Halal, Kosher and Caribbean Meals choices every day. The Trust’s

35 Catering Service also employs a Catering Liaison Officer who will meet any patient to consider their individual dietary requirements and agree meal plans which meet their specific religious, cultural or ethical needs. ▪ Use of Interpretation & Translation (including All services are able to commission interpreting related PALS and Significant events reports) services when required. The Trust’s Clinical Directorates have their own arrangements using local interpretation services. All Mental Health Act information has been translated into the main languages used by Black and Minority Ethnic communities in Greater Manchester.

4. Patient ▪ Complaints: Statistics on number of complaints by Trafford data Disability, Ethnicity, Gender, by Experience & equality issues, location, brief outline and details of service ADD, AFS, AYSS. Complaints ** resolution.

▪ Summary of actions/lessons learnt in addressing No data. EDHR related complaints

▪ Patient experience: Breakdown of satisfaction No data. levels in patient experience surveys by protected characteristics of patients 5.Communicati  Consultations with equality groups Quality account gone to consultation. ons &  Targeted communications Engagement  Equality events Face Book and Twitter Black and Minority Ethnic Dementia Event, Refugee and Asylum Seekers, Female Genital Mutilation Steering Group Deaf Awareness Week, Multi Faith Event, EDS public grading.

36 6. Management  Numbers attending EIA training The Trust does not currently provide Analysis of  EIAs completed and published Effect training.  E&D training by % of workforce achieving EIA part of action plan and objective 5 Trusts specific KSF levels of competency Equality and Diversity training is mandatory for all  Access to training by protected characteristics of staff staff. No analysis of protected characteristics  Breakdown of staff undertaking PDR by provided. protected characteristic No PDR data presented.

7.Sub-  Where other organisations are used to carry Data submitted basic clauses. NHS Terms and contracting out work, outline of the equality clauses or Conditions for the Provision of Services used by the criteria for selection included in contracts / Trust. tender specifications 8.Equality  National Performance Framework EDS Equality objective plans in place, and service level Delivery action plan and equality objectives. EDHR actions presented. The Trust is currently System (EDS) developing structures to involve and train local Equality Act interest groups to carry out EDS annual public 2010 Objectives grading. The Trust’s Equality, Inclusion. Recovery and Diversity Group have agreed to plan and hold three public grading events in April, May and June 2014.

GMW Summary

37 GMW have provided significant data that demonstrates robust compliance with the Equality Act 2010 and the PSED. Performance against the schedule is robust with good levels of evidence provided. There is data provided by the Trafford directorate that provides information by service areas, and organisational/ service area action plans for specific EDHR improvement. However, as with all current providers it will be important in the next stages of EDHR development to ensure this data is better utilised to provide greater analysis of patients by the protected characteristics. The organisation has demonstrated its commitment to equality analysis has provided no details of numbers of completed assessments and any EDHR outcomes from these assessments. There are several areas identified for improvements in data quality;

 increasing the numbers of protected characteristic groups overall where relevant,

 enhance existing action plans to cover all indentified gaps in evidence and data quality improvements,

 Improve evidencing of EDHR data utilisation to demonstrate and evidence improvements in patients access, experience and outcomes.

Overall GMW have demonstrated significant delivery of both the PSED and against the equality monitoring schedule. The evidence presented has provided TCCG with significant assurance of EDHR performance and delivery.

Pennine Care NHS FT, Trafford Division Community Services (Community Services Provider)

1. Workforce Breakdown by protected characteristics* Pennine Care Equality and Diversity Sept 2013 Report.  Staff by banding  Recruitment - applications, short-listing and Workforce monitoring data Age, disability,

38 appointments ethnicity, gender, marital status, religious belief,  Training sexual orientation.  Grievances  Sick leave Pay Band, Age, disability, ethnicity, gender, gender  Disciplinaries reassignment, marital status, maternity, religious  Bullying and Harassment belief, sexual orientation. Employment Tribunals (discrimination related)  Leavers headcount Recruitment data June. Age, disability, ethnicity,  summary of relevant issues from exit gender, gender reassignment, marital status, interviews religious belief, sexual orientation

Grievances Age, disability, ethnicity, gender, marital status, religious belief, sexual orientation

Sick leave disability, ethnicity, gender, marital status, sexual orientation.

Disciplinaries. Age, disability, ethnicity, gender, marital status, religious belief, sexual orientation

Bullying and Harassment Age, disability, ethnicity, gender, marital status, religious belief, sexual orientation

Leavers headcount Age, disability, ethnicity, gender, marital status, maternity, religious belief, sexual orientation

Promotions Age, ethnicity, gender, marital status, religious belief, sexual orientation

 Staff survey outcomes Trafford Division took part in PCFT’s annual Staff Survey 2013, the results of which are not available at the time of writing this report.

 Staff network update Staff side groups generic will include some of the protected groups.  Board composition by protected Contained within section 1 data no protected characteristics (Age, Disability, race, characteristic data presented. religion or belief, sex and sexual orientation)

39 2.Service Use / Completed initial audit for equality monitoring data The division currently collects data on the following Data sets and by protected characteristics of patients. fields for patients: Completion Rate Equality monitoring data improvement targets by  Age protected characteristics for patients  Gender  Ethnicity (some services only) Progress against monitoring data improvement  pregnancy and maternity (some services targets by protected characteristics for patients only) Reviewing current data status . Audit of DNA rates by protected groups  Monitoring of services.

 Identify data gaps by protected.

 Recording data and data utilisation for service provision.

 DNA review.

Developing action plan for improvement. Mirroring Pennine Care data returns.

3. Accessibility ▪ Report disability access audit Trafford division is compliant with the requirement to undertake a disability access audit every three years. The last audit was completed in December 2012 and there were no major issues identified. The next audit is planned for 2015.

▪ Availability of Prayer facilities (where appropriate) Policy to be reviewed.

40 ▪ Availability of Halal / Kosher meals for patients and Not applicable staff (where applicable) ▪ Use of Interpretation & Translation (including Data collated, report not available at present time. related PALS and Significant events reports) 4. Patient ▪ Complaints: Statistics on number of complaints by Data available but low numbers. Since April 2013 the Experience & equality issues, location, brief outline and details of division has received 21 complaints and 43 PALs Complaints ** resolution. enquires. The division does not currently collect data by protected characteristics for complaints. However each complainant is sent an equality monitoring form which collects data against two of the protected characteristics, age and ethnicity.

▪ Summary of actions/lessons learnt in addressing No data. EDHR related complaints

▪ Patient experience: Breakdown of satisfaction No data. The division does not currently collect data levels in patient experience surveys by protected by protected characteristic for PALS enquires.Work is characteristics of patients in progress to align the division with PCFT’s the equality monitoring processes for PALS.

5.Communicati  Consultations with equality groups PCFT has a comprehensive communication and ons &  Targeted communications engagement strategy in place with numerous Engagement  Equality events methods of engaging patients and seeking their feedback. At a divisional level we use a variety of other means of engaging with our patients. The largest survey undertaken is the divisional wide bi- annual divisional patient satisfaction survey, which has been reported on in the previous section. We also complete various service specific patient satisfaction surveys. Equality and Diversity Compliance Report for Pennine Care Foundation

6. Management  Numbers attending EIA training PC policies Trafford EA on website.  EIAs completed and published  E&D training by % of workforce achieving

41 Trusts specific KSF levels of competency Training Core Skills to be reviewed.  Access to training by protected characteristics of staff To review Training & PDR.  Breakdown of staff undertaking PDR by protected characteristic Equality and Diversity Compliance Report for Pennine Care Foundation

7.Sub-  Where other organisations are used to carry Pennine Care Data contracting out work, outline of the equality clauses or criteria for selection included in contracts / tender specifications 8.Equality  National Performance Framework EDS Review EDS 1 position and reviewing EDS 2 to Delivery action plan and equality objectives. develop action plan for implementation. Check PC on System (EDS) their position. Equality Act Equality Objectives 2010 Objectives http://www.penninecare.nhs.uk/Equality- objectives.htm

Pennine Care Trafford Division Community Services Summary

Pennine Care Trafford Division Community Services has provide a level of assurance that demonstrate a more basic level of compliance at the current time only workforce data was presented as available evidence at the time of producing this report. However, the service provider via several meetings has provided verbal assurance of compliance to the PSED and the equality monitoring schedule. TCCG will continue to work closely with Pennine Care and the Trafford Division to ensure significant progress is made against the PSED and the schedule. Where evidence has not been presented the Trafford division has provide details of current issues and identified ways forward to improve the

42 situation. The following section provides an overview of Trafford Division Community Services methodology for improvement.

The service aims to be sensitive to the needs its service users, TPS is working to have a reflective diverse representative workforce. At the time of writing this report Trafford division is working with its parent organisation, PCFT, to include the divisional equality monitoring data in all future PCFT statutory equality data reports, and should be considered as work in progress.

The overall quality of data used in this report is mixed throughout the services and where available is generally limited to three of the protected characteristics, i.e. age, gender and ethnicity. It must be noted that the levels of non-assignment of ethnicity however is variable, with the reasons for this being either the information has not been provided by the referrer or the patient declined to declare it. Whilst compiling this report review of the available divisional data has demonstrated there is lack of data collected some of the other protected characteristics which may have important health and well-being implications, such as disability, sexual orientation.

Trafford division is committed to further improving the data it holds and is committed to working with its staff to ensure accurate data is captured and provided, and with our parent organisation to ensure any further equality compliance reports by PCFT includes Trafford Division.

Trafford Division has a named Equality and Diversity Lead who, prior to transfer to PCFT, regularly attended Equality and Diversity lead meetings at Bridgewater Community Health Care Trust and NHS Trafford PCT. Post transfer to the division has identified the need for our E & D Lead to become a member of the PCFT E & D Steering group which leads on the deliver of E & D planning for the organisation and there is an action plan in place to achieve this. The division has

43 also recognised the need for the E & D lead to attend the divisional Quality and Governance meetings to lead and guide on the E & D agenda across the division, with the key focus on patients and service issues.

In order to reduce discrimination the division has an approved Recruitment and Selection policy that all staff comply with when recruiting people to all vacant posts in Trafford. The policy clearly outlines roles and responsibilities and the procedures to follow for those staff involved in the recruitment process. All staff undertaking interviews have completed the divisional recruitment training programme. All newly recruited staff must complete a mandatory corporate and local induction, which includes the completion of Equality and Diversity training, a core session of the mandatory training programme. The E&D training covers all aspects of the Equality Act 2010 and includes the protected characteristics and discrimination. Managers and staff have support and advice from the HR department and a series of HR policies and procedures available to them in the course of their employment duties.

In recognition that some staff need extra assistance in order to contribute in the workplace, we have also implemented the following initiatives:

 flexible working arrangements

 health bank

 personal development plans

 benchmarking to identify areas for improvement in relation to workforce practices

 divisional staff bulletins

 staff engagement events, including staff open forums, divisional management team walkabouts

44 Trafford Division took part in PCFT’s annual Staff Survey 2013, the results of which are not available at the time of writing this report. However an action plan for the division will be developed with input from the E and D lead as required. Trafford Division has an established staff side group that has extensive involvement with the divisional and senior management team. The group provides an essential link between staff and management and are a valuable source of consultation and expertise to ensure that our processes, policies and procedures do not discriminate. Work is in progress to raise awareness of Trafford Divisions staff with the work and purpose of PCFT established staff network groups.

For those services recording service use/data sets/completion rates electronically, Trafford Divison uses Lorenzo as its core PAS system and the data is available and comes directly from this. The division currently collects data on the following fields for patients:

 Age

 Gender

 Ethnicity (some services only)

 pregnancy and maternity (some services only)

The system does not currently allow for the remainder of the 9 characteristics to be recorded. There are a number of Trafford Division’s services whose data is captured manually and general observations suggest there are some protected characteristics of patients and service use that are not currently recorded with these recording systems.

PCFT is currently implementing the Paris PAS system across all the divisions, it is planned to include the protected characteristics groups within the system. Whilst there are no immediate plans to implement the Paris System within Trafford division, we are working with PCFT to align service user/data set completion E & D reports and to strengthen the process for collecting protected characteristic that currently exists in Trafford.

45 Recognising that there are still gaps in some services Trafford plan to work with PCFT to implement an annual service Equality Analysis process that will be undertaken by all service managers to identify any potential access barriers to their services for patients. Where barriers are identified managers will develop action plans to either improve or remove the barriers in order to improve access for patients. The action plan will include training to ensure anybody within the division responsible for future policy development will ensure an EIA is completed correctly before the policy is approved.

From Quarter 3 the division will align itself to PCFT’s equality monitoring procedure and send complainant's equality monitoring form with a statement regarding why the information is collected and how it is used. Work is in progress with the Trust’s Complaints Department and Equality and Diversity Department to establish an appropriate way in which the information collected from the equality monitoring form will be collated, analysed and reported.

Positive highlights achieved by Trafford Division;

 Community Matron with specialist interest in Dementia appointed

 Complaints investigated with relevant action plans implemented

 All patients admitted onto clinical domiciliary caseloads have E & D information recorded

 Patients at end of life entered onto the LCP have their religious and beliefs needs recorded

 Urgent and Enhanced Care service will assess patients who may be at risk of inappropriate admission and ensure they are cared for at home

 Holistic nursing and therapy assessments identify barriers to care so they can be addressed appropriately

46  Hearing loops are available in clinics

 Contract for translation and interpreter services in place

 Experienced based design programme has been undertaken

 Patient incidents are recorded by E D data by PCFT Risk dept

 Patient information leaflets are available in different languages and formats

 Training KPI’s demonstrates compliance with safeguarding and mental capacity training

 The CAN common process improves outcomes and reduces duplication for children with a complex and or additional need.

 Holistic health, education and social care assessments are simultaneously co-ordinated to highlight need and outcomes

 The voice of the child/ young person is central to the assessment process

 Children with sensory needs (hearing and visual impairment) are supported in education

 Safeguarding training compliance for all staff

13.TCCG Work Force Profile

Workforce for TCCG is significantly lower than the PCT with a total number of staff at 76 people. There is no statutory requirement to provide a workforce profile with less than 150 employees. This sections provides an sample overview of current Trafford workforce profile it should be noted that with staff numbers being so small no statistical reliable inference

47 can be made as to whether the workforce is representative of the working age population. The addition of a single individual can dramatically alter any statistical analysis.

Data Quality

Data has been collected for Ethnicity, Gender, Age, Disability, Sexuality, Martial Status & Religion

No Of Do not No of Records wish to records % Section filled in disclose Undefined blank Total Completed Employment Type 76 0 0 0 76 100.0% Age Bands 76 0 0 0 76 100.0% Gender 76 0 0 0 76 100.0% Ethnicity 73 1 2 0 76 96.1% Disability 56 4 16 0 76 73.7% Religion 51 7 18 0 76 67.1% Sexuality 49 9 18 0 76 64.5% Marital Status 54 0 2 20 76 71.1% Pay band 76 0 0 0 76 100.0% Data has been sourced from the ESR system and the data is at 30/9/13.

Although the data quality appears to have significantly improved from the TPCT data from last year, categories such as disability and sexuality either have a majority of non disclosures, actual low numbers of positive reporting within these categories. The actual numbers of employees who have declared their ethnic origin as other than white status is 17%, which compares to approximately 19% of the Trafford population.

48 68% of the work force is female and 32% is male in comparison to 51% female and 49% male in the total Trafford population. Of the total number of full time employees 37.3% are male and 62.7% are female. Of the total number of part time employees 20% are male and 80% female.

49 The majority of staff can be found within pay bands 5 to 8, there are more female employees in bands 6,7 and 8. TCCG will continue to evaluate its workforce by the protected characteristic to identify any potential trends that will inform the organisational development plan.

14.Conclusion

TCCG is establishing a stronger EDHR base on which to support its aspirations and plans for the commissioning of health services that meet the needs of the people of Trafford. EDHR is embedded into the governance, reporting and performance framework and built into the commissioning cycle infrastructure whether within TCCG or in the commissioned services from GM CSU. The CCG continues to work with key partners and stakeholders to ensure the fullest legal compliance against the requirements of the Equality Act 2010. The focus at this stage of reporting has been to establish a solid foundation and challenge leading to improved EDHR reporting performance and assurance of legal compliance from its main providers of acute, mental health and community services. The work will be rolled out to include all providers. TCCG understands and is fully committed to ensuring that a robust evidence base drives EDHR working which supports and underpins its local strategic health goals. This work will continue to be rolled out to include all providers and seek the necessary EDHR data quality enhancements. This work is intended to lead to improved clarity of focused activity to deliver fit for purpose health services for all protected characteristic and vulnerable groups in the Trafford Area. It is recognised that one critical area for significant improvement will be to drive improvement in the area of EDHR data utilisation. TCCG will be working to support its providers and key stakeholders in establishing enhanced analysis and use of EDHR data to identify and eliminate barriers to patients access, poor patient experience and improve patient outcomes.