Equality & Rights Action Plan 2013-17
This document outlines the actions we will take to work towards our Equality & Rights Outcomes.
Outcomes not processes
An outcome is an end result, for example having staff who are all aware of Equality and Rights issues and who can treat all people with dignity and respect. A process is how to get there, for example a training plan or revising the contents of the training course.
We have tried to focus the actions in this plan on outcomes as much as possible. Sometimes it is difficult to measure outcomes, but during the life of this action plan we will develop ways of doing this.
The actions we have included here are in addition to equality activities mainstreamed in other plans. This means that we have not referred to work set out elsewhere which will promote Equality and Rights. This is to ensure that the action plan is as clear and concise as possible and addresses current gaps in services, information and evidence. The Equality Act makes no specific reference to people on low incomes but all work subject to impact assessment as outlined in this action plan takes account of the impact of socio-economic position on tackling health inequalities.
International standards in equity for health care
The action plan is based on the International Standards for Equity of Health Care, developed by the World Health Organization’s network of Health Promoting Hospitals & Health Care Services. You can find out more about these standards here:
There are 5 separate Equity Standards which are described here:
- Standard 1: NHS Lothian is fair and equitable in the way it develops its policies and strategies, and in the way it employs its workforce.
- Standard 2: Access to NHS Lothian’s healthcare services is equitable.
- Standard 3: NHS Lothian’s healthcare services deliver an equitable quality of care to all patients.
- Standard 4: NHS Lothian involves and consults with people in an inclusive and equitable way when developing services or policies.
- Standard 5: NHS Lothian promotes equality and diversity in its work with partners, in its contracts and in its procurement of goods and services.
For more information about how we identified these outcomes and actions, see the NHS Lothian Equality Outcomes 2013-17. You can find this on the NHS Lothian website at
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Equality & RightsAction Plan 2013-17
Standard 1. NHS Lothian is fair and equitable in the way it develops its policies and strategies, and in the way it employs its workforce
Outcome / Action / Output / Deliver by end of / Lead / GeneralDuty reference / Human & Children’s Rights reference
1.1 All healthcare developments, policies and plans take account of the diversity of needs and characteristics of patients and the community / Improve and review impact assessment processes, including monitoring, training, quality and the performance of NHS Lothian committees and services in completing and acting on impact assessments
Assess the performance of key services using the International Equity Standards taking a risk-based approach, with stakeholder involvement
Establish a policy to ensure that senior decision makers address equality & diversity in their performance management arrangements
Develop effective processes to gather evidence and data about equality, poverty and all protected characteristics / Various compliance performance measures, impact assessment action plan.
Number of services subjected to assessment and follow up actions completed
Policy approved, objectives in place for all relevant managers
Evidence bank accessible to all staff to support impact assessment and service improvement. Implementation of Additional Support Needs and protected characteristic data collection workstream across all services. / March 2015
March 2017
March 2016
March 2017 / EQIA Steering Group
Equality leads
Director of Human Resources & Organisational Development
Director of Public Health & Health Policy / Advancing equality of opportunity / Supports development of a Human Rights and Children’s Rights based approach
1.2 The NHS Lothian workforce better reflects the diversity of the population it serves, and staff with protected characteristics are represented appropriately at all levels of the organisation. / Develop more targeted training for members of interview panels in equal opportunities
Establish a programme to improve workforce monitoring across all protected characteristics
Develop provision of mentoring, coaching and other support for staff with protected characteristics once they are in post.
Improve the knowledge and skills of Employee Relations staff so that they are better able to provide support when an employment issue concerns equality & diversity / Number of staff completing equal opportunities in recruitment training by job family and pay band
% disclosure of protected characteristics increases
Various outputs including number of staff supported by protected characteristics, by pay band, job family
Improved monitoring of Employee Relations cases by protected characteristic; improved reported outcomes / March 2015
March 2015
March 2015
March 2015 / Director of Human Resources & Organisational Development / Advancing equality of opportunity, eliminating discrimination, improving relations between groups / Human Rights Article 3: No torture or humiliating or degrading treatment.
Article 4: No slavery or forced labour.
Article 8: Right to a private and family life.
Article 9: Freedom of religious belief.
1.3 The pay gap between staff of different genders, ethnicity and for disabled staff is reduced. / Prepare and publish an equal pay statement for NHS Lothian
Deliver equal pay plan in priority pay bands and job families. Identify and review horizontal and vertical occupational segregation / Statement published with demonstrable staff and Partnership involvement
Narrower % pay gap and gender imbalance in key job families between male and female staff
For disabled staff and BME staff / March 2014
March 2015
March 2017 / Director of Human Resources & Organisational Development / Eliminating discrimination / Supports development of a Human and Children’s Rights based approach
1.4 There is improved dignity at work for all staff and volunteers. / Launch and publicise a revised Dignity at Work policy and clear organisational values
Facilitate the establishment of robust staff-led networks for LGBT, disabled and BME staff
Implement Gender-Based Violence policy and develop monitoring system for staff reporting and ensure appropriate training, support and referral pathway. / Organisational Values programme delivered, Dignity at Work policy revised, Management Culture plan delivered, NHS Scotland annual staff survey
Staff networks in place, number of meetings and members
Policy and procedures in place, monitoring system developed / March 2017
March 2015
March 2015 / Director of Human Resources & Organisational Development / Eliminating discrimination, improving relations between groups / Human Rights Article 3: No torture or humiliating or degrading treatment.
Article 8: Right to a private and family life.
Article 9: Freedom of religious belief.
2. Access to NHS Lothian’s healthcare services is equitable
Outcome / Action / Output / Deliver by end of / Lead / General Duty reference / Human Rights reference2.1 Access to health services is more equitable for people with protected characteristics / Develop data gathering on how people access primary and acute health services
Develop and implement programme of training and awareness raising with GP surgeries on registration policies, equality & diversity and communication. To include all protected characteristics.
Review of interpreting & communication support arrangements, implement development plan including awareness-raising and training for staff in working with interpreters, and participation in NHS 24 pilot on videoconferencing for BSL interpreters
All patients who need support receive this to encourage improved access to health services and anticipatory health care, through cultural bridging. / Establishment of baseline and robust data set to include all protected characteristics
Patients report improved experience (e.g. through Better Together survey); other measures e.g. number of GPs and reception staff trained.
Plan will include various measures; improved level of service data will identify areas for further improvement. Number of staff trained; improved patient and interpreter experience.
Through use of service ethnicity data; review of referrals, attendance etc by all protected characteristics and additional needs; monitoring of patients supported by Minority Ethnic Health Inclusion Service. / March 2017
March 2017
March 2016
Ongoing / Director of Public Health & Health Policy
Equality Leads, Public Involvement Co-ordinators, Development Managers, Public Health Practitioners
Senior Manager, Staff Bank
Director of Public Health & Health Policy, Equality Leads / Advancing equality of opportunity / Supports development of a Human and Children’s Rights based approach.
2.2 NHS Lothian has minimised architectural, environmental and geographical barriers to its services / Develop the way that Estates & Facilities assess and improve theaccessibility of all NHS Lothian buildings, including improving links to local access panels and making better use of service data in implementation plans. / % of estate assessed as non-compliant. Grading of buildings identifies areas requiring improvement; capital plan addresses these. / March 2017 / Director of Facilities & Estates / Eliminating discrimination / None.
2.3 Health promotion and public health interventions are inclusive, reach all intended audiences and address stigmain the community / Develop and implement specific health promotion activities in a range of subjects for people with protected characteristics (e.g. sexual health, tobacco, substance misuse). / Interventions delivered, service data demonstrates reach through analysis of results using equality and diversity monitoring. / March 2015 / Director of Public Health and Health Policy / Advancing equality of opportunity / Human Rights Article 8: Right to a private and family life.
Children’s Rights Articles 24: Right to health and 28: Right to education
3. NHS Lothian’s healthcare services deliver an equitable quality of care to all patients
Outcome / Action / Output / Deliver by end of / Lead / General Duty reference / Human Rights reference3.1 Patients with protected characteristics have a more personalised, individualised service where they are better able to exercise their independence, control and autonomy with an advocate if needed, and where their rights are protected. / Develop the Compassionate Care and Delivering Better Care programmes to improve the way services involve patients, family and carers in decisions about the care of patients with protected characteristics.
Services use patient data to ensure that care is person-centred, making use of additional support needs and equality data. This includes provision of information.
Carry out a strategic review of Human & Children’s Rights risks and opportunities. / Patient feedback, patient experience quality indicators generate data by protected characteristic/additional need
See additional needs workstream in outcome 1.1
Review complete, report published, actions identified and monitored. / March 2017
March 2017
March 2014 / Chief Nurse, Quality & Professional Standards
Director of Public Health & Health Policy
Equality Leads / Advancing equality of opportunity. / Supports development of a broad Human and Children’s Rights-based approach.
3.2 People in Lothian are more assured that health services will respect their dignity and identity. / Communications and awareness-raising activities to encourage service usersto self-identify their protected characteristics or additional support need.
Implement Gender-Based Violence Strategy, to include further development of routine enquiry and awareness-raising of the risk of Gender-Based Violence in relation to forced marriage, Female Genital Mutilation and Human Trafficking. / Patient feedback, Better Together surveys etc. Increase in recording of patient protected characteristics and additional needs – see outcome 1.1
Service monitoring data demonstrates implementation.
Annual reporting of progress to achieve measurable outcomes / March 2017
March 2017 / Equality Leads
Nurse Director, Director of Public Health & Health Policy / Eliminating discrimin-ation, improving relations between groups. / Human Rights Article 2: Right to life.
Article 3: No torture or humiliating or degrading treatment.
Article 8: Right to a private and family life.
Children’s Rights Article 19: protection from violence and abuse
3.3 Staff are better equipped to deliver health care that takes into account patients’ protected characteristics, health literacy needs and dignity / Review training provision to allow for more targeted provision and content, including:
- developing understanding about the intersections/overlaps in people’s identities e.g. disabled LGBT people
- understanding of the equality & diversity contexts that may inform a service user’s health engagement
- understanding about Do Not Attempt Resuscitation policies for people with life-limiting conditions
- recognition of age-related transitions in service provision
- training in how to ask patients questions about protected characteristics or about their family, significant other or next of kin
- training in the implementation of a Human Rights and Children’s Rights approach
Service data and patient experience demonstrate improvement. Increased recording of patient data including protected characteristic and additional needs.MEHIS reports number of staff supported to provide culturally competent services through building their capacity. / March 2017 / Director of Human Resources & Organisational Development
Equality Leads / Eliminating discrimination, advancing equality of opportunity, improving relations between groups. / Supports development of a broad Human and Children’s Rights-based approach.
4. NHS Lothian involves and consults people in an inclusive and equitable way when developing services or policies
Outcome / Action / Output / Deliver by end of / Lead / General Duty reference / Human Rights reference4.1 NHS Lothian involves with people in a more inclusive and equitable way, including people with all protected characteristics and from across the socio-economic spectrum / Review and develop arrangements for planning, monitoring and evaluating patient and public engagement to improve inclusivity and effectiveness.
Establish ongoing arrangements for patient involvement in Gender Reassignment pathway / Evaluations and data from engagement activities demonstrate improvement in services.
Transgender patient and staff group established / March 2015
March 2014 / Associate Director of Communi-cations
Gender Reassign-ment lead specialist in Public Health / Advancing equality of opportunity, improving relations between groups. / Supports development of a broad Human and Children’s Rights-based approach.
4.2 NHS Lothian ensures that any individual can provide feedback or make a complaint and this is addressed equitably and transparently / Develop existing mechanisms to measure the patient experience so that they are sufficiently detailed to link data to protected characteristics or additional support needs.
Review arrangements for encouraging feedback and suggestions so that all patients have an opportunity to provide these.
Develop complaints procedures so that complaints relating to discrimination are demonstrably treated seriously / As for outcome 3.1
Monitoring of feedback and suggestions demonstrates improvement by protected characteristic.
Monitoring of complaints demonstrates takeup and resolution by protected characteristic / March 2017
March 2015
March 2015 / Director of Public Health & Health Policy
Chief Nurse, Quality & Professional Standards
Director of Human Resources & Organisational Development / Eliminating discrimination. / Human Rights Article 6: Right to a fair hearing.
Article 10: Freedom of expression.
Children’s Rights Article 12: Respect for the views of children
5. NHS Lothian promotes equality & diversity in its work with partners, in its contracts and in its procurement of goods and services
Outcome / Action / Output / Deliver by end of / Lead / General Duty reference / Human Rights reference5.1 NHS Lothian’s partner organisations and suppliers operate in a way that is consistent with its approach to the promotion of equality / Review and update standard contractual terms and conditions and Service Level Agreements to include specific requirements relating to promotion of general duty.
Identify key partner organisations and support them to monitor protected characteristics of service users, and use the resulting data to evaluate the accessibility and effectiveness of these services and improve the extent to which they promote equity, build social capital and address poverty. / Contracts and agreements revised to specify how they will take account of the needs of people with protected characteristics and those on low incomes. Monitoring provides baseline for ongoing development work with suppliers and contractors.
Monitoring and reviewing service data demonstrates improvement in accessibility and outcomes and identifies any barriers to access.
Social capital outcomes in service level agreements contribute to building community cohesiveness and community safety / March 2015
March 2016 / Health & Social Care Partnerships, Director of Finance, Director of Strategic Planning
Equality Leads / Eliminating discrimination, advancing equality of opportunity, improving relations between groups. / Supports development of a broad Human and Children’s Rights-based approach.
5.2 Individuals and communities who are vulnerable to, or victims of hate crime feel safer and more secure / Improved knowledge and understanding of hate incidents and hate crimes and reporting mechanisms including the involvement of police when necessary, through greater integration of hate crime issues in mainstream staff training.
Joint Hate Crime campaigns make better use of local data.
Improved publicity for joint hate crime arrangements with other organisations, e.g. police.
NHS Lothian representation on Hate Crime Strategic Development Groups and the Community Safety Partnerships / Issue of hate incidents/hate crime are integrated within both mainstream and equalities training, and in HR policies.
Increased reporting of hate incidents and hate crimes on DATIX system. Monitoring of referrals to support organisations and police
As above.
As above
Increased reporting and monitoring of hate crimes reported through multi-agency groups / March 2014
March 2016
Ongoing
2016 / Director of Human Resources & Organisational Development, Director of Public Health & Health Policy, Equality Leads
Equality Leads
Equality Leads
Equality Leads / Eliminating discrimination, improving relations between groups. / Human Rights Article 2: Right to life.
Article 3: No torture or humiliating or degrading treatment.
Article 8: Right to a private and family life.
Article 9: Freedom of religious belief.
Children’s Rights Article 19: Protection from violence and abuse
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