Equality Report
How we perform against the NHS Equality Delivery System outcomes – Case Studies and evidencefor 2gether NHS Foundation Trust
February 2012
Glossary of abbreviations and terms
EDS / Equality Delivery SystemNHS / National Health Service
‘Protected characteristics’ / The nine characteristics protected under the Equality Act 2010:
1.Age
2.Disability
3.Gender reassignment
4.Pregnancy/maternity
5.Marriage/civil partnership
6.Religion/belief
7.Race (or ethnicity)
8.Sex (or gender)
9.Sexual orientation
‘Disadvantaged groups’ / Sometimes called ‘marginalised’, ‘hard-to-reach’ or ‘seldom-heard’ groups, these are people who experience inequalities in health, healthcare and employment, but who are not specifically protected by the Equality Act. They can include homeless people, sex workers, people who misuse substances, people with low socio-economic status, and people living in rural isolation.‘Local interests’ or ‘Local interest group’ / Patients, the public, voluntary sector organisations, members of the community, staff and staffside (trades union) organisations who have an interest in what we do.
BME / Black Minority Ethnic
GRIP / Gloucester Recovery in Psychosis
CQC / Quality Care Commission
NIHCE/NICE / National Institute for Health and Clinical Excellence
1.Introduction
1.1The Equality Delivery System
The Equality Delivery System (EDS) is a tool that has been developed by the NHS for use by organisations that commission and provide NHS services. We use the EDS in partnership with patients, the public and staff to review our equality performance and to identify future priorities and actions.
The EDS consists of four goals:
1. Better health outcomes for all
2. Improved patient access and experience
3. Empowered, engaged and included staff
4. Inclusive leadership at all levels
The goals are underpinned by 18 outcomes. These are set out in the appendices. The aim is to achieve equality in these outcomes across the nine characteristics protected by the Equality Act, i.e. age, disability, gender reassignment, pregnancy/ maternity, marriage/ civil partnership, religion/ belief, race, sex, and sexual orientation.
1.2About this report
This document describes some of the work that we have done which we believe shows how we achieve the EDS outcomes. We have described our ‘best practice’ and recognise that we may not achieve this quality of service consistently or perhaps not on every occasion, however it enables us to strive for excellence.
For each of these goals and their related outcomes, we have set out:
- Examples of how we deliver our services
- How we are doing compared to regional or national averages where possible this information is available
- For people with protected characteristics why they may experience different outcomes
- Where appropriate information for other disadvantaged groups such as homeless people, sex workers, drug users, people with low socio-economic status(NB ‘disadvantaged groups’ are an optional extension of the EDS).
- How people from across the ‘protected characteristics’ are involved and engaged in decisions;
- How we have integrated equality considerations into our mainstream business processes;
- Where we think we can improve equality in this area, and the plans we have in place to achieve this.
- Drawing up this report was the first stage in the EDS process.
- We shared examples of our ‘best practice’ case studies at engagement events on the 6th December 2011, 16th, 19th and 27th January 2012. About fifty people attended and came from voluntary and community organisations, other public sector organisations, were service users or carers, and for this Trust, were our members and Governors plus staff. These people represent our ‘local interest’ groups. At these events we asked participants to describe the barriers they or others face in accessing health care or achieving healthy outcomes. We asked what an ‘excellent’ health service would look like and many people described services which reflected key aspects of our ‘best practice’ examples.
- This report (as at February 2012) is just one stage in our processes. We are seeking your assessment of how we are doing. You can work with us to agree ‘grades’ for each outcome, based on the evidence in this report and your own assessment of how we are doing. For each outcome one of four grades is possible:
Excelling – Purple
Achieving – Green
Developing – Amber
Undeveloped – Red
- The final stage will asking you to work with us to agree a number of equality objectives which we can embed into business planning. Objectives need to be agreed and published by 5th April 2012.
1.3About the NHS in Gloucestershire
Three NHS organisations provide services in Gloucestershire. All three organisations actively supported the countywide events and individual organisations have supplemented this with their own events. Briefly this is what they each do:
NHS Gloucestershire
NHS Gloucestershire is made up of two separate parts – the Commissioners and Gloucestershire Care Services.
NHS Gloucestershire (Commissioners)
NHS Gloucestershire is responsible for commissioning (buying) healthcare for the population of Gloucestershire (approximately 602,000 people).It is responsible for a budget of £910 million to spend this year (2010/11).
NHS Gloucestershire commissions (buys) services from Gloucestershire Hospitals NHS Foundation Trust, 2gether NHS Foundation Trust, Gloucestershire Care Services, Great Western Ambulance Service, and voluntary sector organisations. NHS Gloucestershire also supports local GP Practices (and Clinical Commissioning Clusters) to buy health services to meet the needs of their local communities.
NHS Gloucestershire Care Services
Gloucestershire Care Services provides a wide range of community health services to people living in Gloucestershire. These include:
- Community (or district) nursing
- Therapy services for adults and children (such as physiotherapy, occupational therapy, podiatry and speech & language therapy),
- 8 community hospitals providing inpatient, outpatient and emergency care
- Out-of-hours services
Gloucestershire Care Services currently employs over 3,325 staff.
For more information about equality and diversity in NHS Gloucestershire contact
Gloucestershire Hospitals NHS Foundation Trust
The Gloucestershire Hospitals NHS Foundation Trust provides acute elective care (which means it carries out planned operations, from hip and knee replacements, to heart surgery and cancer care) and specialist care (including emergency care, brain injury care). The Trust serves people in Gloucestershire and beyond. The organisation runs both Cheltenham General and GloucestershireRoyalHospitals. The doctors and nurses also see patients at clinics in all of the community hospitals across the county.
Gloucestershire Hospitals NHS Foundation Trust employs more than 7,500 staff and sees in excess of 700,000 patients each year.
The organisation is a Foundation Trust. This means it has more control over its finances, and it has a Council of Governors and a large group of Members, who are made up of people from across Gloucestershire. Their role is to suggest ideas and to tell the Trust what it is doing right, and how it can be improved.
For more information about equality and diversity in Gloucestershire Hospitals NHS Foundation Trust contact
1.4About our organisation
2getherNHS Foundation Trust
2gether NHS Foundation Trust is the main provider of mental and social health care in Gloucestershire and Herefordshire. We provide services for individuals experiencing learning disabilities, mental health or substance misuse problems.
At any one time we provide services to over 10,000 people and offer education and support to carers, families and schools. We employ over 2000 staff across the two counties.
As a Foundation Trust we have over 6000 memberswho influence our activities both directly by contacting the Trust and through locally elected representatives who sit on the Council of Governors.
For more information about equality and diversityin 2gether NHS Foundation Trust contact
2.Our performance against EDS Outcomes
Goal 1: Better health outcomes for all
Goal 1 states: “The NHS should achieve improvements in patient health, public health and patient safety for all, based on comprehensive evidence of needs and results”. There are five outcomes under Goal 1.
Goal / Narrative / Outcome1. Better health outcomes for all / The NHS should achieve improvements in patient health, public health and patient safety for all, based on comprehensive evidence of needs and results / 1.1 Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalities
1.2 Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways
1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly
1.4 The safety of patients is prioritised and assured. In particular, patients are free from abuse, harassment, bullying, violence from other patients and staff, with redress being open and fair to all
1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups
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Outcome 1.1: Services are commissioned, designed and procured to meet the health needs of local communities, promote well-being, and reduce health inequalitiesOutcomes: how are we doing? / This Trust does not commission services – lead responsibility sits with the commissioning arm of NHS Gloucestershire. However this Trust works closely with the commissioners to agree our services and take into account how health inequalities can be reduced. An example of how we do this is the work of the Intensive Health Outreach Team. This team works across services and sectors to meet the health needs of people with a learning disability and thereby reduce health inequalities.
What are the health inequalities faced by those with a learning disability?
There are about 11,000 adults with learning disabilities in Gloucestershire. This number is expected to rise by 15% by 2030, including a 59% increase in those aged 65 years and over because people are living longer. People experience ill health as often as or more often than the general population, but are less likely to seek or receive appropriate healthcare and often die at a younger age.
- Older adults are more likely to develop dementia, with those who have Down’s syndrome developing dementia up to 40 years earlier than the general population.
- Epilepsy is at least 20 times more common in people with a learning disability
- Family and other carers can find it difficult if they cannot access the support they need to help them care.
Local figures for dementia are currently only available at GP register level. However these figures probably under-estimate the true prevalence of dementia which may be difficult to diagnose in the early stages. This is being addressed locally as part of the implementation of the National Dementia Strategy. Meanwhile it is suggested that dementia is likely to be an increasing burden on the health economy in the coming years[i].
Outcomes: how are we doing? / What services do we have which meet the health needs of local communities, which promote well-being, and reduce health inequalities?
The Intensive Health Outreach Team was set up in 2009 to address the health inequalities set out in the Department of Health’s ‘Valuing People’ paper 2001, and Valuing people now: a new three-year strategy for people with learning disabilities : Department of Health - Publications.
The 2001 paper sets out the higher prevalence of health needs as experienced by those with a learning disability, their higher levels of marginalisation and lower levels of access to health care.
Working with the Commissioners in the county and in recognition of the poorer health outcomes for people with a learning disability the Intensive Health Outreach Team were seen as a way of enhancing mainstream services for this group of people. The purpose of the team is to bridge the gap between services, enabling more information to be available to ensure a better diagnosis. In addition the Intensive Health Outreach Team can work with carers to ensure they have the right skills and can better record and report symptoms which can again be used to improve the information available for a diagnosis.
Theteam have no fixed working pattern. Each service user is assessed to determine their specific requirement for support taking into account risks and the intensity of support required. The team have developed a ‘reasonable adjustment’ tool which can be used for example when working in partnership with another health provider. This tool may be used where the team identify that an individual because of their health needs requires a forty minute consultation with their GP rather than twenty minutes and that to provide the person with access via a back door to the Surgery would address their levels of anxiety. These actions actively address health inequalities and improve health outcomes for an individual.
Outcomes: how are we doing? / How have we worked across services and different parts of the NHS to meet the health needs of local communities, promote well-being, and reduce health inequalities?
The Commissioners set up a multi agency group which included representatives of Gloucestershire NHS Hospitals Trust, 2gether NHS Foundation Trust, NHS Gloucestershire and GPs. This group looked broadly at what could be done to improve the health outcomes for people with a learning disability, looked at what was known about the population and what was known about their needs.
The Intensive Health Outreach Team and the Learning Disability Hospital Liaison Nurses are both good examples of collaborative working which reflect the principles of the work of this group. The Learning Disability Hospital Liaison Nurses have a strategic role to improve health outcomes at the pre-admission stage, during a hospital admission and on discharge. They can ensure that the ‘reasonable adjustment tool’ is utilised and work collaboratively with the Intensive Health Outreach Team.
The Intensive Health Outreach Team is able support service users in a wide range of settings including people's own homes, assessment and treatment units, care homes, local authority run respite centres as well as delivering care at the general hospitals alongside mainstream primary and secondary health services. The team has also been a valuable resource for signposting carers, and playing an educational role to other professionals, service users and carers. They can deliver services 24hours per day.
The Hospitals Trust now has in place a ‘flagging’ system to indentify someone who is known to have a learning disability. This can help with ensuring that health inequalities can be addressed on admission. Working with GPs it is now possible to track the journey of someone with a learning disability through all NHS services to better meet health needs.
Engagement / A case study
An individual of 64 years of age with a diagnosis of Down’s syndrome, learning disability and Dementia and was referred to the Intensive Health Outreach Team in late 2010. This person also had many other health issues including an under active thyroid, arthritis, epilepsy, type 2 diabetes and a pace maker.
Since the onset of Dementia there had been a loss of ability to move independently and this person would no longer use their few known words.
All skills for self care and feeding had also been lost and this individual was now totally reliant on carers for all activities of daily living, and also was refusing to leave the house.
This individual was living in a care home and had been referred to the Intensive Health Outreach Team by the East County Learning Disability
Team which is another 2gether service.
The Intensive Health Outreach Team visited the home. The team made an assessment to determine why this individual was so distressed. Their observations were taken over an extended day to ensure a comprehensive picture was obtained.They:
- observed pressure areas which had previously been undetected
- undertook blood glucose monitoring to provide baseline information for the GP
- considered whether medication was impacting on levels of distress
- observed that ‘poor positioning’ could be improved by Occupational Therapy input
- observed the person’s reaction to seeing reflections in the windows of the conservatory after dark
The team took the following actions:
- Worked with the GP and the GP undertook a review of medication
- Through the GP, the team made contact with the District Nurse
- A new care plan was drawn up which supported physical and mental wellbeing
- Made a referral to Occupational Therapy for a review of equipment
- The team provided the care home staff with basic training to identify early warning signs of deteriorating health and thereby reduce the
- A joint care plan was developed with the GP for the care home staff
- Worked with care home staff to ensure that this person received the right level of personal care to reduce incontinence which was causing distress
- the team gave advice on promoting a suitable environment which included ensuring that the person was not left in the conservatory at times when their own or others’ reflections could be seen which because of the Dementia caused distress.