Equality diversity and human rights strategic framework

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Title: Equality, Diversity and Human Rights Overarching Strategic
Framework
Title

Version: 1 (20.04.10)

Reference Number: SET001 -2010

Supersedes: Action for Equality
Supersedes

Significant Changes: To meet the legislative requirements of the Trust’s and
revised process for embedding, monitoring and surpassing compliance of
Equality, Diversity and Human Rights

Originated By: Berenice Postlethwaite
Originator or
modifier

Designation:

Modified by: Mark Nesbitt

Designation: Equalities Consultant
Ratification

Referred for approval by: Operational Management Group

Date of Referral:
Application

All Staff
Circulation

Issue Date: March 2010.

Circulated by: Service Equality Team

Dissemination and Implementation:

Review Date: March 2013.
Review

Responsibility of: Head of Equality and Diversity (SET)

Date placed on the Intranet: Please enter your EqIA Registration Number here:

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

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

Patients Organisational Workforce Key Stakeholders

All Staff SET/ITS HR / OD&T PPI

Patient Experience Equality, Diversity & Working Practices Board/Council of
/Quality Campaign Human Rights Scheme Policies Governors

Equality Impact
Care Quality
Assessment E&D in Employment PFI Partners
Commission
Framework

E&D Learning and Induction and
NHSLA Development Mandatory Volunteers
Framework Training

ITS
Patient Profiling/ IWL / IiP/ Third
Wayfinding Best Practice Stonewall/etc. Sector/Communities
Guide

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


5. Equality, Diversity and Human Rights Strategic Aims

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 Evidence compliance with current Evidence compliance with the requirements of current
current equality legislative legislative acts (core strands of equality) legislation and the Human Rights Act
requirements and regulatory Equality Act, Human Rights Act
guidance
Evidence compliance with the Top quartile CQC / NHSLA compliance
requirements of Care Quality Progress annual updates on the Equality Scheme
Commission and NHSLA

Demonstrate excellence in EPIT NHS North West EPIT – Excellence level

Identify and mitigate key Strategic Risks Risks identified and key mitigations updated annually
regarding equality, diversity and Human
Rights.

Complete all actions each year 100% actions achieved for each year of Framework and
Scheme

Assured that all of its policies, Develop an annual programme for Equality Impact Assessment (EqIA) programme for all Divisions,
procedures and services are free Equality Impact Assessments (EqIAs) to Departments and Services
from direct and indirect be completed
discrimination
Integrate process into Service Review Full integration of EqIA process / Majority of EqIA completed

Framework as part of the Service Review Process

All Trust policies assessed Trust assured that all service are non- discriminatory

Provide additional training and support Increased number of ‘accredited’ staff year on year
for staff to enable the EqIA framework to
be fully embedded within the Trust

A fully inclusive organisation, with Further develop Equalities Equalities Implementation Group is fully established and seen
equality, diversity and Human Implementation Group as a leading Strategic group across the Trust by
Rights embedded in everything staff/stakeholders/partners
that we do
Promote and publicise through all Ensure that the Framework is embedded across the service
available marketing channels the positive Promote our Framework
approach to embedding equality and
diversity

Increase the number of Diversity Increased number of Champions/Co-ordinators year on year
Champions/Coordinators and enhance
their role across the Trust

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 Monitor compliance with quality The best NHS Foundation Trust employer (Highest NHS Trust
equality of opportunity central to assurance initiatives in employment upon NHS Staff Survey). Achieve high level results with
the recruitment and development IiP/Stonewall and other external standards


of staff
Develop an equality, diversity and A comprehensive E&D learning and development framework is
Human Rights Learning and in place and achieving high rates of participation and
Development Framework satisfaction

Pro-active, positive action to target Deliver HR Equality actions annually
under representation across the
organisation

Monitor and evaluate work with partners Increase local employment (staff residing in Manchester)
to maximise training and employment within the Trust
related initiatives for unemployed
people living in our local communities.

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 Increase and maintain the accuracy of Increased collection of patient profile information year on year
meet the identified needs of our Patient Profile and accessibility High level of patient profiling intelligence which is utilised by
patients, service users and their information across all core strands, staff.
communities including socio economic

Increase the proactive usage of resident Maximum use of guidelines for staff on communication to
profile information and delivery of meet all our patients’ needs
tailored services

Increase the use of alternative means of High satisfaction from patients regarding accessibility (NHS
communicating with Patients Patient Survey)


Ensure that Patients Religious and Increased use of Chaplaincy Services year on year
Spiritual needs are met High satisfaction from patients regarding meeting their
religious needs (NHS Patient Survey)

Ensure that communication and access Accessibility and Wayfinding is seen as exemplary by external
barriers are removed from all accessibility auditor
services/properties delivered by the
Trust.

Delivering innovative services to Develop projects to improve the health Worked on local projects in partnership to deliver Local
vulnerable people to help improve and wellbeing of our local communities Community Co-hesion Targets – increased number of projects
their health and well-being 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 Work with our main contractors and Contractor/Supplier ‘Trust Equality Standards’ being met by
with a cross section of suppliers to ensure the ethos and values larger contractors (£500k plus) through contract management
stakeholders and partners. of the Trust re: equality and diversity are
embedded within their workforce Develop an E&D Contractor forum to share good practice and
experiences

Embed equality, diversity and human Embedded equalities in commissioning / procurement
rights into the commissioning and Published diversity objectives and outcomes for Partnering
procurement process Supply Chain


Share best practice across partnerships, Trust is seen as a good ‘partner/neighbour’ (local survey)
locally, regionally, and nationally Participation in key National, Regional and Local Partnerships
ensuring the Trust benefits from best practice

A creator of innovative Increase the effectiveness and diversity Effective involvement and engagement with patients and
opportunities for all communities of patients and public involvement public to affect services they receive (NHS Patient Survey)
to participate in the decisions, activities
which affect the delivery of
services they receive Ensure the Trust Board and Council of Effective partnership through strategic engagement of the
Governors can obtain views and opinion Third Sector
from a wide range of diverse
communities

Develop a strategic partnership with the SLAs with key strategic Third sector organisations across
Third Sector Manchester/North West

Deliver an annual stakeholder event to Successful event year on year (Participant Feedback)
outline progress and joint working to
tackle the Trust key themes
MN - 20.04.10


Equality diversity and human rights strategic framework

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