equality diversity and human rights strategic framework

Trust Strategic Framework 2010-16 Page 0 of 16 See the Intranet for the latest version. Version Number: 1 (20.04.10)

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Title: Equality, Diversity and Human Rights Ov erarching Strategic

Framework Version: 1 (20.04.10) Reference Number: SET001 -2010

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Supersedes: Action for Equality Significant Changes: To meet the legislative requir ements of the Trust’s and revised process for embedding, monitoring and surpa ssing compliance of Equality, Diversity and Human Rights

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Originated By: Berenice Postlethwaite Designation: Modified by: Mark Nesbitt Designation: Equalities Consultant

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Referred for approval by: Operational Management Gr oup Date of Referral:

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All Staff

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Issue Date: March 2010. Circulated by: Service Equality Team Dissemination and Implementation:

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Review Date: March 2013. Responsibility of: Head of Equality and Diversity ( SET)

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Equality, Diversity and Human Rights

Overarching

Strategic Framework

2010-2016


Section Contents Page

1 Introduction 3

2 Purpose 4

3 Roles and Responsibilities 5

4 What is the Framework? 5

5 Equality, Diversity and Human Rights Strategic Aims 7

6 The 2016 Position Statements 7

7 Key Strategic Objectives 8

8 Equality Impact Assessment 8

9 Consultation, Approval and Ratification Process 8

10 Implementation 8

11 Monitoring 9

12 References 9

13 Associated Documents 10

Appendix A – Measures of Success 11


1. Introduction 1.1 Central Manchester University Hospitals NHS Foundation Trust (The Trust) is the

leading Trust for research and teaching in the North West, the largest provider of specialist services in the North West, and is one of three NHS providers of secondary services within Manchester. The Trust was established in 2001 to incorporate Manchester Royal Infirmary, St Mary’s Hospital for Women and Children, Manchester Royal Eye Hospital, the University Dental Hospital, and Royal Manchester and Booth Hall Children’s Hospitals.

1.2 The Trust is a centre of excellence for healthcare research with a long standing and

extremely successful academic partnership with the University of Manchester. The success of this partnership now sees the Trust as one of a small number of organisations in England which has attained Biomedical Research Centre (BRC) status.

1.3 The Trust has delivered its financial duties during 2007/08 and our business plan

sets out strong financial plans through to 2012/13 and beyond. Recent changes to the Payments by Results (PbR) regime, and in particular the evolution of tariffs for specialist services, now means that the real costs of delivering these major element of our services are better recognised. This represents a significant financial benefit to the Trust and is factored into our financial modelling.

1.4 Our recent performance for total time in A&E has fallen short of national targets and

our own ambitions. Despite the successful implementation of a range of initiatives within the Trust and in conjunction with our commissioners, the planned bed reduction within the Full Business Case for our New Hospitals Development has only been partly mitigated within the local health economy. The Trust has now initiated plans to get back on track to deliver the A&E target early in 2008/09. Data for April and May 2008 shows that we have made significant improvements in our performance and are on track to deliver the target by the end of quarter 1.

1.5 We are currently five years into a six year Private Finance Initiative (PFI)

development that will facilitate the centralisation of adults and children’s services on the main Oxford Road site. This development, known as the New Hospitals’ Development (NHD), is a unique opportunity for the Trust to make a step change in the quality and effectiveness of patient care delivery for both secondary services for the local population and also specialist services for the population of the North West. The scheme concludes in 2009/10 and is on schedule, and on budget.

The Trust’s Corporate Values 1.6 These are still under development but should reflect the following statements

People First… 1.7 Central and core of the Trust’s whole existence is that it provides services to over

1m people every year and employs over 8,500 staff. People first, puts people in the spotlight whether they are staff, patients, visitors, stakeholders or partners.


Doing The Right Thing… 1.7 We want all our staff across the whole organisation to value the concept that they

should always do the right thing. This means that they should not routinely and systematically follow the same course of action but change to the make the difference in the way they relate to their fellow colleagues and deliver services to patients, visitors or stakeholders.

Being The Best…

1.8 The Trust will always strive to be best across a variety of external measures, Best Value, National NHS Surveys (Patient/Staff), CQC, National Legislation, National Indicators, NHS initiatives, Local Surveys, External Staff Surveys (IiP/Stonewall index/etc).

Be Good Neighbours…

1.9 This is how and why we choose to work together, locally, regionally, and nationally. We pride ourselves, as one of the largest employers and procurer of services and goods in Manchester. By using this strength and by working with the local communities we can be a key partner in local regeneration and community investment. We acknowledge that the Trust can help tackle social as well as health inequalities. Being a good neighbour is where the Trust, in partnership with others, can make Manchester and in particular, our local communities a better place to live and work.

2. The Purpose of the Framework 2.1 The purpose of this Framework is to provide guidance to Trust staff, Board and

Governors about one of the Trust’s key priorities and cross cutting themes, i.e. promoting equal opportunities, human rights and challenging discrimination. It will achieve this through a number of strategic aims and key strategic objectives which are detailed within this Framework.

2.2 It brings together the Trust policies, strategies and procedures relating to equal

opportunities, achieving change for disadvantaged communities and working to eliminate health inequalities.

2.3 The principles of this Framework will be applied to everyone working (paid or

voluntary) directly for or with the Trust. 2.4 The Trust will deliver this Framework by:

• Mainstreaming equality and diversity in all aspects of the Trust’s work • Cascading corporate equality actions and targets into all divisional plans,

departmental plans, programmes and projects • Building effective partnerships with key national, regional and local

organisations • Challenging partners and providers to improve equality performance through

service delivery • Influencing key decision makers to provide leadership in all equality issues


3. Roles and Responsibilities It is the responsibility of... 3.1 The Chair of the Trust Board, the Chief Executive and Executive Directors, to lead

and model commitment to it through their behaviour, attitude and effective use of their influence and authority. They are accountable for ensuring that the Trust provides adequate resources to further develop and implement this Framework.

3.2 Executive Directors, Directors and Senior Managers of service areas, to ensure the

implementation and progress of the Framework. 3.3 The Executive Director of Nursing as the executive lead of equality and diversity to

provide the strategic link and coordinate the delivery of this Framework. 3.4 The Assistant Director – Patient Services as the operational lead, for ensuring the

effective implementation of this Framework across the Trust 3.5 The Service Equality Team (SET) has an overall function to ensure all areas and

aspects of the Trust are working towards and meeting the Trust’s key strategic equality, diversity and human rights strategic aims.

3.6 All staff to participate fully in implementing the Framework. 3.7 Partners and Stakeholders to work with us to achieve our aims 4. What is the Framework? 4.1 The Equality, Diversity and Human Rights Framework is made up of a series of

documents that combined, provides guidance on the Trust’s approach to embed equal opportunities, access and outcomes for all.

4.2 The chart below indicates how some key teams across the Trust support the

delivery of the Framework to achieve the Trust aims. It also shows how key strategic documents fit into the structure of this framework.


Equality, Diversity and Human Rights

Strategic Framework

Organisational

SET/ITS

Equality, Diversity & Human Rights Scheme

Equality Impact Assessment Framework

Induction and

Mandatory

Training

ITS

Best Practice

Guide

Workforce

HR / OD&T

E&D in Employment

E&D Learning and Development Framework

Working Practices Policies

IWL / IiP/ Stonewall/etc.

Key Stakeholders

PPI

Board/Council of Governors

PFI Partners

Volunteers

Third Sector/Communities

Patients

All Staff

Patient Experience /Quality Campaign

NHSLA

Care Quality Commission

Patient Profiling/ Wayfinding

ITS Interpretation and Translation Service SET Service Equality Team HR/OD&T Human Resources / Organisational Developme nt and Training PPI Patient and Public Involvement Team


5. Equality, Diversity and Human Rights Strategic A ims 5.1 Trust’s Equality, Diversity and Human Rights Framework 2010-2016 has four key

overarching strategic aims:

• Moving Beyond Compliance We will work to ensure that we move beyond simply complying with the current

and any forthcoming legislative and regulatory framework, which we work under. By moving beyond compliance we aim to reach excellence in all areas of our work.

• Creating An Inclusive Workplace

We will strive to be the best employer across the NHS by ensuring we provide a supportive, inclusive and safe place to work.

• Surpassing Patient Expectations We will work to ensure that all patients, family members and visitors expectations are surpassed before, during and after they have been with us.

• Strength In Numbers

We will work in partnership with our staff, patients, visitors and stakeholders to ensure that we deliver high quality services and invest in our local communities.

6.0 The 2016 Position Statements 6.1 The following ‘positional statements’ will be used to measure success of the

strategic aims. By 2016 the Trust will strive to be:

• Surpassing compliance with current equality legislative requirements and regulatory guidance

• Assured that all of its policies, procedures and services are free from direct and indirect discrimination

• A fully inclusive organisation, with equality and diversity embedded in everything that we do

• An exemplar employer with equality of opportunity central to the recruitment and development of staff

• Adaptable in service provision to meet the identified needs of patients, service users and their communities

• Delivering innovative services to vulnerable people to help improve their health and well-being

• Successful in our partnership work with a cross section of stakeholders and partners

• A creator of innovative opportunities for all communities to participate in the decisions, which affect the delivery of services they receive


7.0 Key Strategic Objectives 7.1 To achieve the four Strategic aims and meet the ‘by 2016’ positional statements, the

Trust will implement and deliver the following key strategic objectives:

• Ensure that the Trust's internal practices and performance are surpassing compliance with equality legislative requirements, Human Rights legislation and regulatory guidance

• Ensure all the policies, procedures and services are free from direct and indirect discrimination

• Continue to embed equality and diversity in everything that we do • Be an exemplar employer, with equality of opportunity central to the

recruitment and development of staff • Adapt service provision to meet the identified needs of our patients, service

users and the wider community • Work with our main contractors and suppliers to ensure the ethos and values

of the Trust re: equality and diversity are embedded within their workforce • Provide opportunities for all service users to participate in the decisions which

affect the delivery of services they receive 8. Equality Impact Assessment 8.1 This policy has been subjected to a Screening Impact Assessment and will undergo

a further assessment during 2010 9. Consultation, Approval and Ratification 9.1 We will consult on this framework, and all the policies and strategies that underpin

it. 9.2 SET held an Equalities Summit on the 15th March 2010 where over 130 members of

staff and invited guests were able to comment upon the framework and other key equality documents

9.3 The final document will be approved by the Trust Board. 10. Implementation 10.1 This Framework will be implemented via a Trust wide implementation plan. 10.2 For further information or advice on implementation of this Framework, please

contact the Service Equality Team.


11. Monitoring our Performance 11.1 The Trust will translate what it says about Equalities, Diversity and Human Rights

into an annual action plan and will monitor its progress and outcomes critically and regularly through the Equality Implementation Group.

11.2 There are a number of statutory and non-statutory requirements relating to monitoring and measuring performance. The following have the most significant impact on the way that the Trust delivers its services.

Equality Act (2010).

11.3 The Trust has developed this overarching Equality, Diversity and Human Rights Framework in response to the recently introduced Equality Act (2010).

Care Quality Commission (CQC) – Essential Standards for quality and safety

11.4 CQC have published guidance for all health and adult social care providers on meeting new essential standards of quality and safety that will apply across the care sector.

11.5 Providers must show they are meeting essential standards as part of a new registration system which focuses on people rather than policies, on outcomes rather than systems.

11.6 The essential standards relate to important aspects of care such as involvement

and information for people, personalised care and treatment, safety and safeguarding. Subject to legislation, the new registration system comes into force for NHS trusts on 1 April 2010. CQC will continuously monitor compliance with essential standards as part of a more dynamic, responsive, robust system of regulation accompanied by new enforcement powers.

11.7 CQC's guidance is focused on outcomes - the experiences people have as a result of the care they receive - rather than on systems and processes. It was widely consulted on earlier this year and places the views and experiences of people at the centre of the regulatory system.

12. References

• Equalities Act 2010 • Commission for Equality & Human Rights - http://www.cehr.org.uk/ • Department of Health (2007) Human Rights in Healthcare – a Framework for

Local Action • Department of Health – Knowledge Skills Framework (KSF) • Department of Health – Improving Working Lives (IWL) – • Department of Health (2010) – The NHS in England Operating Framework • Department of Health – Vital Connection – • Care Quality Commission (CQC) Essential Standards for quality and safety • EPIT – Equalities Monitoring (NHS North West)


13. Associated Documents

• Corporate Integrated Business Plan 2009-10 • Equality, Diversity and Human Rights Scheme • E&D in Employment • Dignity and privacy • All HR polices • Equality Impact Assessment Framework • E&D Learning and Development Framework


Appendix A – Measures of success Moving Beyond Compliance

We will work to ensure that we move beyond simply complying with the current and any forthcoming legislative and regulatory framework,

which we work under. By moving beyond compliance we aim to reach excellence in all areas of our work.

Positional Statement ‘by 2016’ Key actions to achieve Measure of Success

Surpassing compliance with

current equality legislative

requirements and regulatory

guidance

Evidence compliance with current

legislative acts (core strands of equality)

Equality Act, Human Rights Act

Evidence compliance with the

requirements of Care Quality

Commission and NHSLA

Demonstrate excellence in EPIT

Identify and mitigate key Strategic Risks

regarding equality, diversity and Human

Rights.

Complete all actions each year

Evidence compliance with the requirements of current

legislation and the Human Rights Act

Top quartile CQC / NHSLA compliance

Progress annual updates on the Equality Scheme

NHS North West EPIT – Excellence level

Risks identified and key mitigations updated annually

100% actions achieved for each year of Framework and

Scheme

Assured that all of its policies,

procedures and services are free

from direct and indirect

discrimination

Develop an annual programme for

Equality Impact Assessments (EqIAs) to

be completed

Integrate process into Service Review

Equality Impact Assessment (EqIA) programme for all Divisions,

Departments and Services

Full integration of EqIA process / Majority of EqIA completed


Framework

All Trust policies assessed

Provide additional training and support

for staff to enable the EqIA framework to

be fully embedded within the Trust

as part of the Service Review Process

Trust assured that all service are non- discriminatory

Increased number of ‘accredited’ staff year on year

A fully inclusive organisation, with

equality, diversity and Human

Rights embedded in everything

that we do

Further develop Equalities

Implementation Group

Promote and publicise through all

available marketing channels the positive

approach to embedding equality and

diversity

Increase the number of Diversity

Champions/Coordinators and enhance

their role across the Trust

Equalities Implementation Group is fully established and seen

as a leading Strategic group across the Trust by

staff/stakeholders/partners

Ensure that the Framework is embedded across the service

Promote our Framework

Increased number of Champions/Co-ordinators year on year

Creating an Inclusive Workplace

We will strive to be the best employer across the NHS by ensuring we provide a supportive, inclusive and safe place to work.

Positional Statement ‘by 2016’ Key actions to achieve Measure of success

An exemplar employer with

equality of opportunity central to

the recruitment and development

Monitor compliance with quality

assurance initiatives in employment

The best NHS Foundation Trust employer (Highest NHS Trust

upon NHS Staff Survey). Achieve high level results with

IiP/Stonewall and other external standards


of staff

Develop an equality, diversity and

Human Rights Learning and

Development Framework

Pro-active, positive action to target

under representation across the

organisation

Monitor and evaluate work with partners

to maximise training and employment

related initiatives for unemployed

people living in our local communities.

A comprehensive E&D learning and development framework is

in place and achieving high rates of participation and

satisfaction

Deliver HR Equality actions annually

Increase local employment (staff residing in Manchester)

within the Trust

Surpassing Patient Expectations

We will work to ensure that all patients, family members and visitors expectations are surpassed before, during and after they have been with

us.


Adaptable in service provision to

meet the identified needs of

patients, service users and their

communities

Increase and maintain the accuracy of

our Patient Profile and accessibility

information across all core strands,

including socio economic

Increase the proactive usage of resident

profile information and delivery of

tailored services

Increase the use of alternative means of

communicating with Patients

Increased collection of patient profile information year on year

High level of patient profiling intelligence which is utilised by

staff.

Maximum use of guidelines for staff on communication to

meet all our patients’ needs

High satisfaction from patients regarding accessibility (NHS

Patient Survey)


Ensure that Patients Religious and

Spiritual needs are met

Ensure that communication and access

barriers are removed from all

services/properties delivered by the

Trust.

Increased use of Chaplaincy Services year on year

High satisfaction from patients regarding meeting their

religious needs (NHS Patient Survey)

Accessibility and Wayfinding is seen as exemplary by external

accessibility auditor

Delivering innovative services to

vulnerable people to help improve

their health and well-being

Develop projects to improve the health

and wellbeing of our local communities

Worked on local projects in partnership to deliver Local

Community Co-hesion Targets – increased number of projects

delivered year on year

Strength in Numbers

We will work in partnership with our patients, visitors, stakeholders and local communities to ensure that we can deliver the key success

measures outlined within our Equalities, Diversity and Human Rights Strategic Framework.


Successful in our partnership work

with a cross section of

stakeholders and partners.

Work with our main contractors and

suppliers to ensure the ethos and values

of the Trust re: equality and diversity are

embedded within their workforce

Embed equality, diversity and human

rights into the commissioning and

procurement process

Contractor/Supplier ‘Trust Equality Standards’ being met by

larger contractors (£500k plus) through contract management

Develop an E&D Contractor forum to share good practice and

experiences

Embedded equalities in commissioning / procurement

Published diversity objectives and outcomes for Partnering

Supply Chain


Share best practice across partnerships,

locally, regionally, and nationally

Trust is seen as a good ‘partner/neighbour’ (local survey)

Participation in key National, Regional and Local Partnerships

ensuring the Trust benefits from best practice

A creator of innovative

opportunities for all communities

to participate in the decisions,

which affect the delivery of

services they receive

MN - 20.04.10

Increase the effectiveness and diversity

of patients and public involvement

activities

Ensure the Trust Board and Council of

Governors can obtain views and opinion

from a wide range of diverse

communities

Develop a strategic partnership with the

Third Sector

Deliver an annual stakeholder event to

outline progress and joint working to

tackle the Trust key themes

Effective involvement and engagement with patients and

public to affect services they receive (NHS Patient Survey)

Effective partnership through strategic engagement of the

Third Sector

SLAs with key strategic Third sector organisations across

Manchester/North West

Successful event year on year (Participant Feedback)

equality diversity and human rights strategic framework

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