ANNUAL PROGRESS REPORT 2013/14 /
- INTRODUCTION
During early 2013, the CCG Senior Leadership Team reviewed the local equality objectives for the NHS in Hull and developed an Equality and Diversity Plan and Objectives 2013/14 to 2015/16. This work built upon previous discussion with clinicians, stakeholders and diverse groups through attendance at meetings such as the Disability Choices and Rights, Humber All Nations Alliance, Sure Start, Hull City Council, Age Concern, Hull Community Network, Lesbian Gay Bisexual and Transgender Forum and Hull’s People Panel.
In May 2013, the CCG Governing Body approved the Equality and Diversity Plan and Objectives. These have been published on the CCG website, in line with the requirements of the Public Sector Equality Duty.
This update report covering the year to March 2014 highlights significant equality-related activities and achievements for the period April 2013 – March 2014, including specific progress that has been made against the agreed Board Level Objectives and the Equality Delivery System Objectives.
- SIGNIFICANT ACHIEVEMENTS
2.1Staff awareness and training
All CCG staff have access to a computer based training package which includes Equality and Diversity training. This is mandatory for all staff to complete and, as at 15 March 2014, 100% of staff had completed this training – this is in addition to bespoke equality impact analysis (EqIA) training which was commissioning in November 2012.
2.2 Engagement
The Director of Commissioning and Partnerships is now a member of the Divisional Independent Advisory Group and routinely attends the quarterly meetings. The meeting is run by the Humberside Police D-Division and provides an opportunity for a wide range of multi-agency professionals to meet with local community representatives, including representatives of diverse groups/communities.
All engagement events/patient feedback reports contain equality and diversity information and a specific question asked around sharing services to meet the diverse needs of the population.
2.3Work with Humber All Nations Alliance (HANA)
The CCG has regular and ongoing meetings with HANA officers.These provide the opportunity for HANA to raise any issues of concern to Black and Minority Ethnic (BME) communities. In addition, proactive work has included presentations by the CCG and seeking views on proposals at HANA public events.Recent examples include consultation on content requirements for the Patient Guide, which was developed into the “How to get the most from your local Health Services booklet”. This booklet was subsequently translated into the 5 most needed languages (not spoken) following consultation with HANA communities and GP practices. The copy from this leaflet is also available on the HANA website which has the facility to translate it into 67 different languages.
Specific work in relation to refugees and asylum seekers has been led by the Director of Commissioning and Partnerships through the Hull Health and Wellbeing Board leading to changes in the way the needs of this group are met in primary care.
2.4Provider Compliance
Systems are in place to monitor healthcare provider compliance with the Equality Act. This starts at the service specification development stage, is checked as part of procurement and monitored through regular and robust contract monitoring arrangements.
2.5Complaints/Incidents
Systems are in place to monitor complaints and incidents both at the CCG and occurring at service provider level. These are specifically monitored in relation to equality and diversity issues. In 2013/14, there have not been any complaints or incidents relating to accessibility issues.
2.6Primary Care Translation Service
The CCG has recently procured a new company to provide its Translation and Interpretation services. This system was introduced across primary care, following extensive consultation with organisations and individuals who support potential users of the translation service.A particular gap in relation to the availability of interpreters who could support clients with British Sign Language was addressed as part of this procurement.
2.7Website
A new CCG website is currently being procured and will be fully compliant with the Web Content Accessibility Guidelines. The existing website includes google translate and an accessibility bar that lets users change things like the font sizes and colour scheme to help those with visual impairments.
An update on the progress against each of the Board level objectives is attached and has been RAG rated. There are no red rated objectives. Suggested amendments are highlighted in red
- RECOMMENDATIONS FOR 2014/15
The Integrated Audit and Governance Committee is asked to:
i)Note the content of this update report, the attached objectives update and supported the suggested revisions – marked in red
ii)Take assurance from the progress made during the last 12 months
iii)Note and support the recommendations for 2014/15 as follows:
a)Review and update the CCG information that is available on the internet; ensuring that EqIAs are published and that the identified outcomes are monitored
b)Refinements are made to the E&D data received through Contract Management Boards in order to ensure that the sometimes variable content is improved (over the next 3-6 months) and that triangulation with provider complaints and incident dataincluded in order to demonstrate transparency
c)Update the Equality Delivery System (EDS) assessment in line with EDS2
d)Undertake specific work with the BME community to check out the survey report findings of “raising concerns and making complaints” which showed that ‘BME respondents were significantly more likely than white British respondents to have been discouraged by staff from taking action’.
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Board Level Equality and Diversity Objectives 2013/14 to 2015/16
Objective / Lead / Milestone / Time frame / Delivered by / Progress Update and RAG RatingInformation relating to equality and diversity will be updated and held in a centralised repository. This will include guidance and templates for Equality Impact Assessments (EqIAs), demographic information and useful resources and links to further information. / Julia Mizon / Review of all current documentation and links
Collation of current and accurate documents
Design of central area on NHS Hull CCG intranet and launch to area / October 2013
November 2013
December 2013
Timescale extended to April 2014 / Kerry Lynn
Quintina Davies
Kerry Lynn
Quintina Davies
Kerry Lynn
Quintina Davies / Off-Track
This timescale slipped due to staff absences and a subsequent change in delivery lead.
Supporting Evidence
The information in relation to equality and diversity is available and in use by staff (ie EqIA paperwork). However, the information needs to be published on the CCG Internet.
Flow chart processes for Equality Impact Assessments – from template to publication with requirements and responsibilities. / Julia Mizon / Simple flow chart for process developed / October 2013
Timescale extended to April 2014 / Quintina Davies / On-Track
The original timescale set for this work was too ambitious in the context of other CCG work priorities.
Supporting Evidence
A flow chart process has been developed. This will be approved by the Planning and Commissioning Committee and published on the CCG website with the EqIA template by the end of April 2014.
Further development of training and development materials to ensure mandatory requirements are upheld and innovative and inspiring training can be provided at all levels. / Alison Dubbins / Full review and appraisal of training received and required
Review and location of appropriate training
Implementation of training for new starters and annual requirements for all staff / March 2014
Timescale extended to March 2015 / Alison Dubbins
Alison Dubbins
Alison Dubbins / On-Track
This timescale was extended as a result of a change in the CCG structure.
Supporting Evidence
An introductory equality and diversity training session was held for all CCG staff in November 2012.
All staff have access to a computer based training package which includes Equality and Diversity training. This is mandatory for all staff to complete and, as at 15 March 2014, 100% of staff had completed this training. There is a requirement for this training to be updated every three years. All new starters are expected to complete their on-line training within the first 3 months of starting with the CCG and this is reviewed at their first appraisal.
To complement this, a portfolio of knowledge and skills training for all CCG managers is being developed and will be rolled out to staff over the next 12 months – i.e. completed March 2015. This will incorporate equality and diversity.
All staff are also expected to identify their training needs, including any additional needs in relation to Equality and Diversity, as part of their quarterly and annual appraisals. Any identified requirements will be reviewed and training provided to an individual or team, as required.
Carry out equality impact analysis on policies, strategies and decisions about services. / Julia Mizon / Ensure that all policies, procedures, plans, and proposals are EqIA’d to a high standard / Review April 2014 / All Staff / On-Track
Supporting Evidence
An Equality Impact Analysis tool has been developed and shared with all staff. A system is now in place to ensure that all policies, procedures, plans and proposals are EqIA’d and the results used to influence the outcomes of decisions. The Director of Commissioning and Partnershipsreviews and approves all EqIAs to ensure that they are of a high standard and consistent quality. Where appropriate, all papers submitted to the Governing Body and Committees are checked to ensure that an appropriate EqIA has been done. No decisions will be made without this assurance.
See sections 5 and 6 for more information.
Publish all EqIAs with actions to remove or reduce any risks of adverse outcomes on employees, service users or other people who share characteristics protected by The Equality Act 2010 / Julia Mizon / All approved and verified EqIAs to be added to a collated and accessible section of the Internet
All EqIAs to be assured in board meetings and though a consistent process. / Ongoing:
Following review timescales
Following all Board and Committee meetings / Emma Shakeshaft
Mandy Hodgson / Off-Track
Supporting Evidence
Systems are in place to ensure that EqIAs are completed wherever relevant and appropriate. These are quality checked by the Director of Commissioning and Partnerships prior to sign off and subsequent approval as part of the decision making process. The completed EqIAs need to be published on the CCG Internet and outcomes monitored. This action is therefore currently classed as ‘off-track’ due to delays with establishing a system to ensure the backlog of completed EqIAs are published – this is being addressed. The CCG website is due for re-launch in early 2014 and this will be a priority action. Further consideration in 2014/15 is also needed to ensure that the results of EqIAs for service specifications and service resign programmes are published in a meaningful way so they are both easy to find and understandable.
All policies will be reviewed and indexed for requirements, with those of the highest scoring requirements being addressed first.
(Once work completed reviews will be as part of renewal of policy, with oversight to the annual E&D report.) / Julia Mizon / All policies and procedures to be reviewed, amended and published to staff (intranet)
- Human Resources
- Commissioning and Partnerships
- Business Intelligence
- Finance
- Quality and Performance (Clinical)
- Corporate Governance/ Engagement
October 2013
Sept 2013
Sept 2013
October 2013
December 2013 / Emma Kirkwood
Phil Davis
Joy Dodson
Danny Storr
Emma Corbet
Mike Napier / On-Track
Supporting Evidence
Human Resources – Assessment 100% complete. All HR policies have been identified as a high priority for EqIA review. All HR policies are scheduled to be reviewed and available in draft form by the end of June 2014 for staff consultation/approval during 2014/15. In 2013/14, there have been 8 policies reviewed, updated and EqIAs completed. These are in the process of being formally approved.
Commissioning and Partnerships –All general commissioning policies are currently being reviewed. The review process includes EqIA assessment and formal approval by CCG Planning & Commissioning Committee. The overall process is managed by Director of Commissioning & Partnerships.
Business Intelligence – Not Applicable. The CCG does not have any specific BI policies in place. Any new BI policies would routinely include an EqIA as part of their development.
Finance–Assessment 100% complete. In addition, all finance policies and procedures have been reviewed, updated and EqIAs completed. These are undergoing the final stages of approval before being published on the portal by 31March 2014.
Quality and Performance (Clinical) – Assessment complete. Policies are currently being updated and EqIAs will routinely be completed as part of their development and review process. All Health & Safety Policies have been updated and EqIAs completed.
Corporate Governance/ Engagement – CCG engagement and corporate governance policies / frameworks are in the process of being reviewed. The review process includes EqIA assessment and formal approval by the Integrated Audit & Governance Committee.
Interpretation of the staff stress levels survey and proactive actions to address requirements for ensuring the wellbeing of staff within the CCG. / Emma Latimer / Survey to be run and analysed
Annual Staff review to incorporate stress survey questions. / July 2013
April 2014 / Emma Kirkwood
Alison Dubbins / On-Track
Supporting Evidence
The staff stress survey was undertaken and completed in summer 2013. The actions identified from the outcomes of the survey are being taken forward through the Organisational Development plan. An Employee Engagement Working Group has been established to support implementation and actions include management training, performance management, stress awareness training, etc.
The annual staff review took place in January 2014.
Make arrangements to monitor our progress against objectives and evaluate the effectiveness of the action taken. / Julia Mizon / Ensure that E&D progress of objectives and action plans are reported to the Quality and Performance Committee
To review objective and action plan annually
To report on annual progress and target areas for improvement / Quarterly from October 2013
March 2014
April 2014 / Kerry Lynn
Quintina Davies
Kerry Lynn
Quintina Davies
Quintina Davies / On-Track
This action resulted in a change in delivery lead in year.
Supporting Evidence
Systems are in place to routinely monitor progress of implementing Equality and Diversity throughout the organisation. The first progress report against equality objectives was submitted to the November 2013 meeting of the Quality and Performance Committee.
This report provides an annual update on progress made as at the end of March 2014. Information will also be routinely published in the CCG Corporate Annual Report.
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Equality Delivery System Actions 2013/14 to 2015/16
Key
= Priority
= actions required by associates and to link with CCG
- Better Health Outcomes for All
Goal/ Outcome / Actions / Lead / Measure / Time Frame / Progress Update and RAG Rating
1.1 / Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities.
- To increase GP practices sign up to the Annual Health Check for People with Learning Disabilities DES to 100% Access to those eligible by 2014.
Annual Reviews
Baseline to be obtained from LAT
Monitoring and progress through Local Area Team (LAT) / March 2014
Ongoing monitoring / On-Track
88%
Supporting Evidence
In terms of the LD DES target 50 of the 57 practices (88%) have signed up to the DES (information from NHSE) as at February 2014.These 50 practices cover 86% of the CCG total population. The 7 outstanding GP practices have all been visited by a Learning Disability Specialist Nurse and offered training/the opportunity to sign up to the DES. The Wellbeing service, delivered by CHCP, worked with GP practices to deliver the target. This service is commissioned by Hull Public Health and the CCG will continue to monitor uptake.
1.2 / Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways.
- Embed Equality and Diversity as a fundamental part of the commissioning cycle.
- Ensure all EqIA’s are completed for all services and commissioning proposals
- Continue to review hard to reach groups and endeavour to liaise in an appropriate manner.
Mandy Hodgson
Phil Davis
Sue Lee / All EqIA’s reviewed by Director of Commissioning and presented to appropriate committee’s and boards.
Published EqIA’s with actions identified and completed.
Requirements are detailed in service specifications.
Routine reports of information with associated E&D analysis.
Monitor developments and progress in connecting with hard to reach groups and positive engagement. / Quarterly reviews of reports and E&D information via Quality and Performance Committee
Annual equality and diversity report – required date to be confirmed. / On-Track
Supporting Evidence
Equality and Diversity is recognised as an important part of the commissioning cycle. All new service strategies, service specifications and commissioning policies are required to have a completed EqIA prior to submission to the CCG Planning & Commissioning Committee.
All service re-design proposals are incorporated within the work plan of the engagement team who ensure that tailored engagement work is undertaken with the aim of reaching all members of the local community, particularly diverse groups. All feedback reports contain equality and diversity information and a specific question is asked around shaping services to meet the diverse needs of the population.