diversity & equality - west london nhs trust€¦ · equality and diversity and (ii) monitoring...

West London NHS Trust of 19

Policy D3 First date of issue: August 2003 This is current version D3/007 October 2018

Policy: D3

Diversity & Equality

Version: D3/07

Ratified by: Trust Partnership Forum

Date ratified: 18th October 2018

Title of Author: Head of Diversity

Title of responsible Director Director of Organisation Development and Workforce

Key Stakeholders: Trust Partnership Forum

Date issued: 15th November 2018

Review date: November 2021

Target audience: All staff Trust-wide

Disclosure status: B: Can be disclosed to patients and the public

EIA / Sustainability

EIA_Pre_Review_Part1 August 2018.pdf



Equality & Diversity Statement

The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed.

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed.



Version Control Sheet

Version Date Title of Author Status Comment

D3/01 August 2003

HR New Policy Issued

D3/02 September 2006

HR Revised Policy

D3/03 23rd January 2010

Diversity Lead Revised Policy issued

Policy has been updated to take account of changes in Equality legislation and the introduction of new rights prohibiting unlawful discrimination on grounds of age, sexuality and religion. Reference is also made to national drivers as well as various inspectorate standards. Revised Policy presented and approved at 5th Jan 2010 Operations board meeting.

D3/04 February 2012

Diversity Consultant

Revised Policy Issued

Policy has been updated to take account of the additional duties within the Equality Act as well as the requirements of the new NHS Equality Delivery System. Monitoring arrangements have also been strengthened to better integrate equality within the Trust’s core business.

D3/05 May 2012

12th July 2013

Diversity Consultant

Ratified by TMT 9th May 2012

Re-issued to reflect Organisation and Department name changes. No changes to content.

D3/06 April 2015

Revised to take account of the new NHS Equality Standards [Equality Delivery System (2) and the Workforce Race Equality Standard.

Trustwide consultation ends 27th May 2015

D3/07 October 2018

Head of Diversity

Ratified & issued

Policy ratified at October TPF meeting



Contents Page no

1. Summary 5

2. Introduction (includes purpose) 5

3. Scope 6

4. Definitions 6

5.

5.1

5.2

5.3

5.4

5.5

5.6

Duties

Chief Executive

Accountable Director

Managers

Head of Diversity

Workforce Partners

All Staff

8

8

8

8

9

9

9

6. Systems and Recording 10

7. Diversity Framework 10

8. Training 11

9. Monitoring 11

10. Fraud Statement 12

11. References 12

12. Supporting Documents 12

13. Glossary of Terms 13

14. Appendices

Appendix A - EIA Tool - Process

Appendix B – EIA Demographic Template

13

14

17



1. Summary

(i) The Equality & Diversity Policy sets out our approach to implementing Equality & Diversity within the Trust. Our diversity is one of our strengths and provides us with a wealth of experience to draw upon. We do not tolerate behaviour that denigrates an individual on the basis of their background. This policy sets out the way in which this may arise and the action that will be taken if this is discovered.

(ii) Any breach of this policy relating to discrimination, harassment or victimisation, should be dealt with via the appropriate HR employment relations procedure. In most circumstances, allegations of a breach should be investigated under the Grievance Procedure.

(iii) The Diversity Unit must be made aware of any employment relations, investigations, or complaints/serious incidents, that arise, that relate to a

diversity issue.

(iv) Derogatory and/or discriminatory statements will be challenged and action taken. The Trust has a duty to provide a safe environment for its staff and service users; consequently, it will consider limiting or withdrawing its services to service users/carers/visitors if their conduct is considered to be violent, abusive and or discriminatory. In some circumstances, it will also seek to prosecute individuals. Please refer to the Trust’s Management of Violence and Aggression Policy (V2)

2. Introduction

2.1 The Diversity and Equality policy of West London NHS Trust is designed to:

Promote an environment that is inclusive to all individuals regardless of background and is intolerant of practices, which may result in the exclusion of any group.

Recognises the importance of valuing individuals and prohibits discrimination and bullying based on the following characteristics, acknowledging the fact that, these groups still experience discrimination and disadvantages on the basis of their age, disability, ethnicity, gender, gender identity, gender expression, maternity/pregnancy status, married/civil partnership status, religion/spirituality, sexual orientation and/ or practices that breach the Human Rights Act.

2.2 We aim to:

Provide the best possible healthcare services that are accessible and are delivered in a way that respects the differing needs of the individual.

Employ staff who are motivated because they feel valued for the contributions they make and reflect, at all levels, the diversity of the population the Trust serves.

Embed our equality and diversity values into our policies and procedures and our everyday practice.



Regularly monitor and report on our equality progress, demonstrating the actions taken to make our Trust more inclusive.

2.3 The Trust also recognises inequitable treatment on the basis of:

social or employment status

health/HIV status

membership/non membership of a trade union

profession/discipline/grade/level in the Trust

status as an ex-offender

This list is not exhaustive and will be updated in light of future legislation and good practice guidance.

3. Scope

3.1 This policy applies to all staff, including agency, bank staff, contractors, seconded staff, students, volunteers and other ad hoc workers/contractors including service users employed by the Trust.

4. Definitions & equality tools

4.1 There are three different ways in which discrimination can occur - direct discrimination, indirect discrimination, and associative discrimination. For more information, please see the Glossary.

Equality Tools: The Trust uses a series of equality tools to achieve its aims of (i) embedding equality and diversity and (ii) monitoring its progress in reducing the differences in experiences of different groups. A list of the tools currently used follows:

4.2 Equality Impact Assessment [EIA] - assesses the implications for different groups of a change in policy. The Trust has developed an on-line EIA tool. See Appendix A to obtain guidance on accessing the tool.

4.2.1 The Diversity Unit will send EIA’s to the Equality Impact Assessment group, to review the quality of EIA’s. Any comments from the EIA Review group will be sent to the EIA author, who will either include the comments within the policy or will consider if practices or actions need to be reviewed to take account of the comments that have arisen.

4.3 Equality Delivery System [EDS (2)] - is a national NHS tool used to integrate equality into its core business. Trusts are required to carry out an assessment to measure its progress every 4 years. The last assessment the Trust carried out occurred in 2016. The outcomes from the assessment informed the development of our current equality objectives and have been published on both the Equality & Diversity page of the website and Trust Intranet ‘The Exchange’.

4.4 Workforce Race Equality Standard [WRES]



The Workforce Race Equality Standard (WRES) has been developed to minimise the difference in experiences between white and black and minority ethnic (BME) staff. It is a national NHS standard that requires all NHS organisations to:

Review and publish data against the nine WRES indicators.

Produce action plans to close the gaps in workplace experience between white and (BME) staff and

Improve BME representation in senior management and Boards.

All trusts are benchmarked against each other and are required to demonstrate improvements annually. Our WRES annual plan is published on the Equality & Diversity page annually, along with the WRES submission data.

4.5 Gender pay gap reporting

Gender pay reporting legislation requires employers with 250 or more employees to publish statutory calculations every year, showing how large the pay gap is between their male and female employees and to then take action to close the gap.

4.6 Positive action

When there is clear evidence of under-representation, time-limited actions can be taken to achieve a more representative workforce. Positive Action may take the form of a statement of encouragement within job advertisements, encouraging under-represented groups to apply for jobs, or specific training for under-represented groups, to provide them with opportunities that previously may not have been accessible.

We are or have done the following:

Disability Confident Policy (√√) - Short-listing applicants with a lived experience of Disability, that meet the minimum criteria listed in the person specification of a job role.

Diversity Champions being included on the interview panels of senior positions to enable our senior interview panels, to better reflect our workforce and wider community and to increase the objectivity, transparency and independence of senior interviews panels.

BME Leadership Development Programme to increase proportion of BME senior managers by providing access to leadership training opportunities;

Encourage applications from under-represented groups in recruitment campaigns;

Creating work experience placements for young people with Learning Disabilities.

4.7 A glossary of terms associated with Equality & Diversity is provided at paragraph 13.



5. Duties

5.1 Chief Executive The Chief Executive has delegated responsibility for ensuring the Trust

complies with its legislative duties within the Equality Act 2010, for its service users and staff.

5.2 Accountable Directors (Executive Directors)

5.2.1 The executive Director of Organisation Development & Workforce will make provision for the investigation of breaches of this policy through other employment relations processes e.g. Dignity at Work Policy, Grievance and Disciplinary procedures.

5.2.2 The executive Director of Nursing & Patient Experience will make provision for the investigation of issues that relate to patient experience through the Complaints or other service related processes. Acts of discrimination and harassment are serious and can constitute gross misconduct, which could result in disciplinary action leading to dismissal.

5.3 Managers

5.3.1 Managers have a duty in addition to their individual responsibility, to foster a culture of inclusion. A manager should role model behaviour that actively promotes equality and diversity. Managers must ensure that the staff they manage:

(i) comply with the standards of this policy;

(ii) promptly challenge behaviour or attitudes that fall below acceptable standards;

(iii) take action promptly if allegations of a breach of this policy are brought to their attention;

(iv) ensure EIAs are carried out by those that lead reviews/ develop new policies or who lead on changing/redesigning services within their area;

(v) ensure their staff are compliant with their equality and diversity mandatory training.

(vi) Managers must also ensure that training/ development referred to within the development needs section of the Personal Development Review [PDR], is taken into account in deciding upon who should access training or other development activity.

5.3.2 The following processes are often subject to complaints of unfairness, consequently managers have a responsibility to do the following to guard against inequality:

5.3.3 Tackling breaches For monitoring purposes, managers must notify the Diversity Unit of any

reported allegations or investigations being undertaken that raise diversity concerns.



5.3.4 Acting-up/training &development opportunities Ensuring that the process used for short or long term vacancies, e.g. acting up

positions, secondments or any other staff development positions, is transparent. All opportunities should be advertised, for no less than 2 weeks.

5.3.5 Training/ development referred to within the development needs section of the Personal Development Review [PDR], must be taken into account in deciding upon who should access training/other development activity.

5.3.6 Sickness management/disability considerations Sickness should be managed in accordance with the Managing Health &

Absence policy. Disability should be taken into account in managing sickness absence, where applicable, and advice should be taken from HR/Diversity Unit before escalating or progressing an individual through the sickness management process, if an individual has a disability.

5.3.7 It is the manager’s responsibility to consider making reasonable adjustments, where work conditions or physical features within the workplace, place an employee with a disability at a disadvantage. Managers should take advice from HR/Diversity Unit and OH in deciding upon the most appropriate reasonable adjustment for the individual.

5.4 Head of Diversity The Head of Diversity has responsibility for providing advice, developing strategy, promoting, and monitoring the overall implementation of diversity and equality within the Trust.

5.5 The Workforce Partners

The Workforce Partners are responsible for communicating the policy within their Clinical Service Units [CSU’s] or Directorates and for supporting their managers in implementing the policy in their areas.

5.6 All staff

5.6.1 All staff are responsible for ensuring that their behaviour and actions do not amount to discrimination, harassment, bullying or victimisation and must recognise the importance of having an inclusive environment that welcomes diversity.

5.6.2 Staff have a responsibility to alert relevant staff about any behaviour that is perceived as being in breach of this policy, either by tackling the issue with the parties directly, or by notifying an appropriate senior manager.

5.6.3 All service users will be treated with dignity and respect and without discrimination in relation to the service that is provided to them. Service users should report any perceived breach of this policy to the Ward Manager, appropriate clinician or patient advocate. Service users are also expected to treat other service users and staff with dignity and respect.



6. Systems and recording

6.1 Any breach of this policy should be reported via the appropriate procedure. If the issue relates to an employment relations issue, the appropriate process should be evoked, e.g. grievance relating to a recruitment process. If the issue relates to an incident within the ward environment, an incident report should be completed and the complaints process should be invoked (if appropriate).

6.2 The Head of Diversity must be made aware of any breech of this policy.

7. Diversity framework

7.1 The following tools are also used to embed equality within our processes:

7.2. Diversity & Equality policy

This policy contains the Trust’s statement of purpose in relation to Diversity & Equality and outlines the differing responsibilities for implementing Equality & Diversity and our monitoring arrangements to ensure the Trust is complying with its equality legislative duties.

7.3 Diversity & Equality Strategy

7.3.1 The Trust’s Diversity & Equality Strategy highlights the disparities that exist for different groups, based upon our staff and patient data experience data, and sets out the action that will be taken to tackle these disparities, eliminating discrimination, and advancing equality of opportunity for different groups within our services and employment practices.

7.3.2 Our progress is monitored via the Trust-wide Equality & Diversity Steering Group and the local diversity strategy groups within the CSU’s. The steering group has responsibility for determining the way in which the objectives agreed by the Board are taking forward across the Trust (see below).

7.4 Diversity Scorecard

This scorecard allows us to monitor our performance in meeting our staff and patient equality objectives. The scorecards are presented at the trust-wide Equality and Diversity steering group on a quarterly basis and local CSU Diversity committees. It is also sent to the monthly senior management team meetings within the Clinical Service Units [CSU].

7.5 The Diversity & Equality Steering Group

The Diversity & Equality governance committees have been revised to strengthen monitoring arrangements within the CSU’s. Both High secure and Forensic CSUs have their own Equality Strategy committee. Arrangements within Local services are different because of the varied nature of the services within its structure. The overarching trust-wide Equality & Diversity Steering Group steers the diversity agenda, monitoring performance of the equality objectives across the Trust. Any disparities in the experiences of different groups are discussed at this meeting, and appropriate actions are determined.



7.6 Staff Networks/Forums

7.6.1 The BME staff network convened to provide peer support to staff and to organise and support celebrate events that promote and celebrate BME role models. .

7.6.2 Race & Culture forum provides staff that are passionate about the role of culture in clinical interventions, an opportunity to learn from each other and influence the development of Trust tools that support the development of cultural competence within its clinical workforce.

7.6.3 LGBT sub-group has been developed to support the Trust in its efforts to be more inclusive in its employment and clinical practices.

7.6.4 Disability forum has been formed in partnership with Staff –side to provide a place for staff with a lived experience of disability, to access guidance and support. The forum also helps staff to help the Trust to identify practices that impact negatively on disabled staff, and provides these staff with an opportunity to influence its practices.

8. Training

8.1 The Diversity Training program is mandatory for all staff and must be undertaken every three years. The following programs all count towards mandatory diversity training:

Diversity session on the Trust’s corporate Induction,

Half day Diversity workshop,

Half day Unconscious Bias training for senior managers and the;

Online ‘e’ Diversity & Equality training program.

8.2 Bespoke training programs are also periodically commissioned based, e.g. LGBT training workshop, honour based violence training, FGM briefing.

8.3 A series of videos highlighting (1) Unconscious Bias; (2) The significance of diversity in clinical practice (3) Gender Identity (Trans) Awareness are available on the Equality & Diversity page of the Exchange and are helpful in raising awareness of the impact of diversity in our every-day practice.

9. Monitoring

9.1 Workforce Partner Our Workforce Partners will support the Diversity Unit in ensuring that approved EIA’s exist for each service development/change within their area.

9.2 Diversity Unit Will monitor the efficacy of this policy across the Trust, as well as looking at

practices within other policies, procedures that could impact upon equality. Any issues of continued non-compliance or other practices that could put the Trust at risk of litigation or considerable public concern, will be escalated to the Trust Management Team so that action can be taken.



9.2.1 The Head of Diversity will analyse staff and service user data to identify possible disparities in the experience of different groups and will take action to identify the reasons behind disparities and make recommendations to minimise reoccurrence in the future.

9.2.2 The Head of Diversity will produce an annual report on the demographic profile of its staff and service users and will also produce a board report summarising actions taken to demonstrate compliance with the Equality Act 2010 within the last financial year.

9.2.3 The Head of Diversity, via the Equality Impact Assessment Review meeting, will review the quality of Equality Impact Assessments.

9.2.4 Regularly review the appropriateness of mandatory Diversity training to ensure that it includes any issues of diversity that have arisen from incidents, employment relation cases, service user and staff survey results or complaints data.

9.2.5 Implement the new NHS Equality Delivery System [2] and Workforce Race

Equality Standard within the Trust’s core business, ensuring appropriate equality objectives are regularly devised in response.

10. Fraud statement

Not applicable

11. References

This policy should be read in conjunction with the following:

B3 Dignity At Work Policy

D4 Disciplinary Procedure

G1 Grievance & Disputes Procedure

T7g Transgender Guidance - caring and respecting our staff and service users

C24 Change Management Policy

R6 Recruitment & Selection Policy

S8 Managing Health and Attendance Policy

The Equality Act 2010

Protection from Harassment Act 1997

Human Rights Act 1998

The Employment Relations Act 1999

The Employment Act 2002

Mental Health Act 1983 (amended) 2007

Work and Families Act 2006

12. Supporting documents

Equality Impact Assessment Tool (online)

Equality Impact Assessment Guidance

Equality and Diversity Strategy



13. Glossary of terms

13.1 Bullying can be described as persistent, offensive, abusive, intimidating, malicious or insulting behaviour, which makes the recipient feel upset, threatened, humiliated or vulnerable, undermining their self-confidence and causes them to suffer stress.

13.2 Direct discrimination - this occurs when a person is treated less favourably than others. Direct discrimination is defined by the Equality Act as discrimination under the 9 protected characteristics listed below:

age, disability, gender identity or gender expression, sexual orientation, marriage and civil partnership, pregnancy and maternity, race, (including colour, nationality, ethnic or national origin) religion or belief (or lack of ), and sex(gender)

13.3 Indirect discrimination – this occurs by applying a provision, criterion or practice which disadvantages people on the grounds outlined above and cannot be justified as a proportionate way of achieving a legitimate aim.

13.4 A genuine occupational requirement is a defence that allows an employer to stipulate that, because of the nature of the job in question, only people of a particular race, religion, age, etc. are eligible. e.g. a Muslim Chaplain being recruited to provide spiritual care to Muslim patients or female staff to work in a rape crisis centre.

13.5 Harassment is defined as being unwanted and unwelcome conduct which is intended to, or which creates, the effect of violating a person’s dignity or creates an intimidating, hostile, degrading, humiliating or offensive environment for that person.

13.6 Institutional discrimination can be described as discrimination that has been incorporated into the structures, processes and procedures of organisations, either because of prejudice or a failure to take account of different social identities.

13.7 Positive Action occurs where an employer takes steps to address an imbalance or redress effects of previous inequality of opportunity e.g. encouragement for under-represented groups to apply for jobs, specific training, etc. However, selection is solely based on merit.

13.8 Positive discrimination occurs where an employer takes steps to address an imbalance; selection is based on merit and membership of a protected group.

13.9 Reasonable adjustments are required under the disability provisions within the Equality Act 2010. Employers have a duty to make reasonable adjustments if a criteria or condition of employment disadvantages a disabled person.

13.10 Victimisation – this occurs where an individual has exercised their rights under equality legislation (or has indicated that they intend to do so) and is treated less favourably as a result. It also applies to persons who support those exercising their rights under the

legislation, e.g. by being a witness within internal or external hearings.

14. Appendices. Appendix A - Equality Impact Assessment Tool - Process Appendix B - Equality Impact Assessment – Demographic Template



APPENDIX A



APPENDIX B

EQUALITY IMPACT ASSESSMENT TOOL

INTERNAL USE ONLY – NOT FOR PUBLICATION

(to be used during departmental reorganisation to identify the impact on different staff groups)

Manager’s name

Directorate

Date

Function or policy

Purpose

Who does it affect? Potentially x staff are to be placed at risk

Consultation process carried out x days

In line with good practice, a number of actions should be adopted to minimise the potential for direct or indirect discrimination against any particular individual from occurring.

These actions include:

Carrying out an EIA screening assessment to consider the effect of this organisational change on the service delivered by staff within Department x.

Attaching the initial EIA screening form to the consultation paper sent to staff identified as at risk. Ensuring that decisions on appointments, identification of ‘at risk’ staff and selection for redundancy is demonstrably fair and transparent; with decisions made only on objective competencies required for the post and on merit

Recording all decisions and providing monitoring for analysing outcomes at the end of the process, which will need to be included in the final EIA for publication, in line with statutory requirements

Please complete as much of this form as possible; if you do not have the requisite information, or parts of the form are not applicable, please state this within the box. You will then need to complete the EIA screening from, by using these findings to inform your responses. If you require any assistance in completing this form please contact the Head of Diversity or your OD Business Partner.



On age grounds, the age profiles of staff within Department x currently and those affected by the proposal are as follows:

Age band Department data as at x Number of staff placed at risk

Outcome

16-34 x 0

35-44 x 0

45-54 x 0

55-64 x 0

65+ 0 0

Total x 0

On grounds of Disability, staff currently within Department x and those affected by the proposal are as follows:

Disability status Department data as at x

Number of staff placed at risk

Outcome

Disabled x 0

Not disabled x 0

Not declared x 0

Total x 0

On grounds of Gender, staff currently within Department x and those affected by the proposal are as follows:

Gender Department data as at x


Outcome

Female x 0

Male x 0

Total x 0



On grounds of Race, staff currently within Department x and those affected by the proposal are as follows:

Race Department data as at x


Outcome

White x 0

Asian x 0

Black x 0

Mixed x 0

Chinese/other x 0

Total x 0

On grounds of Pregnancy/Maternity/Flexible Working, staff currently within Department x and those affected by the proposal are as follows:

PREGNANCY/MATERNITY/

FLEXIBLE WORKING

Department data as x

Number of staff placed

at risk

Outcome

Pregnant x 0

Maternity leave x 0

Flexible Working x 0

Total 0

Conclusion (this section will be fully completed along with the final columns of each table at the end of the restructuring process to determine the new Departmental structure).

Remember to complete the EIA screening form, using the answers obtained above to inform your responses.

Date completed:

Name:

Signature