This is an HTML version of an attachment to the Freedom of Information request 'Ethnic monitoring of Gypsies and Travellers'.

Equality Delivery System 2012 - 2013 
1. 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 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. Public Health data 
Patient and Public 
Equality Impact Assessments are 
Developi
 
 
Helen Bunter 
 
http://www.coventrypct.nhs.uk/Cms
Involvement team 
carried out on all strategies to 
ng 
Documents/c303d852-7dfa-4a9b-
engagement 
identify the particular needs of 
b255-3a267e43bb11.pdf
http://www.coventrypct.nhs.uk
minority groups 
 
/GetInvolved/Consultations 
b. Coventry has the tenth highest 
Via “Respect Yourself” team 
Implementation of the city’s 
Developi
 
 
John Forde 
 
rate of teenage conceptions in the 
http://www.warwickshire.gov.
teenage pregnancy reduction 
ng 
country 
uk/web/corporate/pages.nsf/Li strategy. Appears to be having an 
http://www.coventrypct.nhs.uk/Cms
nks/3647BAC2CE003A58802
impact as figures are beginning to 
Documents/c303d852-7dfa-4a9b-
5736B0038D05D  
slowly improve. 
b255-3a267e43bb11.pdf 
c. People (adults and children) from  Via Coventry Health 
Opportunities for healthy eating 
Developi
 
 
John Forde 
 
lower socio-economic groups are 
Improvement Programme and  and physical activity targeted at 
ng 
 
more likely to be overweight and 
Weight Management Strategy  priority neighbourhoods in 
 
obese than those from more 
Group 
Coventry 
 
affluent areas. 
http://www.coventrypct.nhs.uk
Targeting of Childhood, Weight 
John Linane 
http://www.coventrypct.nhs.uk/Cms
/YourHealth/HealthyWeight 
Management Programmes in 
Documents/7de13d2e-bea2-4537-
 
Warwickshire 
b893-12aa125b8d32.pdf 
d. There is evidence to suggest that  Warwickshire LINk are 
Engagement with target groups to 
Undevelo
 
 
John Forde 
 
lesbians, gay men and bisexual 
carrying out work with the 
understand needs 
ped 
 
men and women (LGB) smoke at 
LGB community 
higher rates than heterosexual men 
 
and women 
http://www.coventrypct.nhs.uk/Cms
Documents/4f439bf0-4b43-4090-
919a-eac6f0ce4872.pdf
 
e. People with psychiatric disorders 
Staff training being carried out  Opportunities though “Every 
Developi
 
 
Caron Williams 
 
are more likely to be heavier 
at St Michaels to offer a 1-2-1  Contact Counts’ approach which is  ng 
 
smokers, more dependant smokers 
stop smoking advice to 
being piloted. 
 
and have smoked for longer than 
service users 
Coventry and Warwickshire 
 
the general population. 
 
Partnership Trust‘s activity on this 
Jacqueline 
http://www.coventrypct.nhs.uk/Cms
should be managed via the CQR 
Barnes 
Documents/4f439bf0-4b43-4090-
meetings 
919a-eac6f0ce4872.pdf
CQUIN in Warwickshire 2011 – 
 
2012. Discuss putting on Coventry 
CQUIN list for 2012 - 2013  

 
f. Men born in South Asia are 50% 
Long term conditions forum 
NHS Health Checks will be 
Developi
  Caron 
Williams 
 
more likely to have a heart attack or 
systematically delivered to the 
ng 
angina than men in the general 
population aged 40-74yrs with 
population. Bangladeshis have the 
invitations being available in a 
highest rates, followed by 
variety of languages.   
Pakistanis, then Indians and other 
Service providers must be 
South Asians. 
experienced in delivering to all 
http://www.coventrypct.nhs.uk/Cms
local populations.  Monitoring 
Documents/59fb6879-92e7-4cf9-
assurance process will be 
8ce9-a4bb54e2d5c8.pdf
undertaken to assess delivery 
 
against demographics. 
g. Elderly people, particularly in 
Information available via 
The public health team of NHS 
Developi
 
 
John Linane 
 
rural areas, are at increased risk of 
virtual wards 
Warwickshire, will be working 
ng 
death during the winter months due 
together with Stratford District 
to fuel poverty 
Council to address the issue 
http://www.warwickshire.gov.uk/We
b/corporate/wccweb.nsf/Links/5619
23165A0CDA6D802578BD003DE7
BD/$file/ReviewofWinterDeaths.pdf
 
1.2 Individual patients’ health needs are assessed, and resulting services provided, in appropriate and effective ways 
Data/information 
Engagement  
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. The Anchor Centre provides 
Focus groups were held with 
Service user volunteers were part 
Achievin
 
 
Helen Bunter 
 
services for homeless and 
service users.  
of the tendering interview process 

vulnerably housed people 
 
Equality Impact Assessment 
Anchor Centre
results were part of the short 
 
listing and tendering process 
b. Smoking during pregnancy 
Via Smoking Cessation group 
Targeting of Service Delivery to 
Developi
 
 
John Linane 
 
increases the risk of infant mortality 
 
North Warwickshire reflecting 
ng 
 
by an estimated 40% Pregnant 
Via University Hospitals 
need.  Pick up through “Every 
 
women who smoke are 25% more 
Coventry and Warwickshire 
Contact Counts Approach” 
John Forde 
likely to suffer a miscarriage. 
 
Via CQR process we should be 
 
(Department of Health 2007).   
Via Any Qualified Provider 
monitoring University Hospitals 
http://www.coventrypct.nhs.uk/Cms
Coventry and Warwickshire on 
Documents/168b6cb0-a841-46b4-
their performance in this area. 
b1f6-fcf0d10f1147.pdf
Need to asses the impact of AQP 
 
on smoking in pregnancy. 
c. Equality Impact Assessment of 
Issue raised at stakeholder 
Engagement with target groups to 
Undevelo
 
 
Caron Williams 
 
Improving Access to Psychological 
event 
understand needs 
ped 
Treatments service showed a 
http://www.coventry.nhs.uk/C
Monitor data available on uptake. 
greater need within the BME 
msDocuments/418b85ce-
Tag to Supporting Long Term 
community (higher rates of 
9821-4ec5-bea0-
Conditions using the Bolton 
depression among Indian and 
7d6067d1652f.doc  
dashboard (Coventry) and risk 
Pakistani women) but uptake has 
stratification (Warwickshire). 
been lower than expected 
http://www.coventrypct.nhs.uk/Cms

Documents/48c3cd1f-bdb8-49d8-
b385-3aa539c1447b.pdf 
1.3 Changes across services for individual patients are discussed with them, and transitions are made smoothly 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. Patients are entitled to copies of 
Patients report that they are 
Work with IT and intelligence at 
Developi
  Caron 
Williams 
 
letters about their health which are 
not always copied into 
University Hospitals Coventry and 
ng 
sent from one health professional to  correspondence about them 
Warwickshire, GEORGE ELIOT 
another 
by consultants 
HOSPITAL and SWFT and local 
http://www.bma.org.uk/images/cons
 
authorities.  
ultantscopyingletterstopatients_tcm
41-190155.doc
 
b. The aim of Choose and Book is 
Coventry LINk report that 
All GPs in Coventry are signed up 
Developi
 
 
Natalie Fuller 
 
to enable patients to choose which 
some GPs are not operating 
to the Referral Support Service. 
ng 
hospital or clinic they go to. They 
the scheme in full. 
The GPs should give the patient a 
should also be able to choose the 
 
leaflet explaining this service. If the 
date and time of their appointment. 
referral proceeds then choice will 
http://www.chooseandbook.nhs.uk/
be offered at this point unless 
patients/whatiscab  
continuity of care or some other 
reason means that the choice 
offered is limited to their previous 
provider 
c. The NHS is founded on the 
University Hospitals Coventry  Work with Clinical Commissioning 
Developi
  Kerrie 
Woods 
 
principles of equal access and 
and Warwickshire reports that  Groups and Local Medical 
ng 
equal treatment for all. This 
information regarding 
Committees to alert GPs to the 
includes providing interpreters to 
patients’ needs for 
need to mention any special needs 
people who do not speak English – 
interpreting services or longer  when referring patients to 
including British Sign Language 
appointments or other 
secondary care. 
interpreters.  
reasonable accommodation 
 
National standards for ethnic group 
for their needs is not always 
The RSS leaflet asks patients to 
and related matters : Department of  given in referral letters 
tell their GP of any special needs, 
Health - Publications 
leading to patients being 
including the need for interpreters. 
It also includes providing support for  turned away or delays in 
people with learning disabilities or 
treatment. 
other conditions which mean that 
 
they need additional support during 
Identified at stakeholder event 
appointments or hospital stays. 
http://www.coventry.nhs.uk/C
http://www.understandingindividualn
msDocuments/418b85ce-
eeds.com/page.php?identity=health
9821-4ec5-bea0-
_and_wellbeing  
7d6067d1652f.doc  

 
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 
Data/information 
Engagement  
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. GP survey 
Through Coventry and 
Analysis of available data 
Developi
 
 
Kerrie Woods 
 
 
Warwickshire LINk 
ng  
b. Hospital surveys and complaints 
Work in partnership with 
Analysis of available data 
Developi
 
 
Jacqueline 
 
Trusts 
ng 
Barnes 
 1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups 
Data/information 
Engagement  
Action 
RAG rating 
Lead 
Evidence 
Jan 2012 
 
 
a. Low rates of screening for bowel 
Currently being undertaken 
Work with practices with a higher 
Undevelo
  Kerrie 
Woods 
 
cancer and cervical cancer 
by LINk 
% of patients from deprived wards 
ped 
correspond to high levels of patients  Via Screening commissioner 
to Improve their rates of screening 
from areas of deprivation in GP 
and working group 
Local campaign to raise 
practices (99% confidence interval) 
 
awareness. 
http://www.coventry.nhs.uk/CmsDo
Possible inclusion in 1° Care 
cuments/c303d852-7dfa-4a9b-
Advisory Group.  
b255-3a267e43bb11.pdf
ID GPs and review data 
 
b. A health equity audit carried out 
Currently being undertaken 
Work with practices in most 
Undevelo
  Kerrie 
Woods 
 
in 2008/2009 identified that women 
by LINk. A report will be 
deprived wards and with the 
ped 
in the most deprived areas and 
available early 2012 
Muslim community to improve 
Muslim women were least likely to 
screening rates 
take up cervical screening 
Local campaign to raise 
programmes 
awareness of screening services 
http://www.coventry.nhs.uk/CmsDo
 
cuments/5373a7e1-18bb-40a2-
97b3-ca45c1c8c97e.pdf
 
c. There has been a recent 
Vaccinations are given by the  Work with Local Medical 
Undevelo
 
 
Kerrie Woods 
 
outbreak of measles in the gypsy 
practice nurse and gypsies 
Committees and Clinical 
ped 
 
and traveller community in 
and travellers report 
Commissioning Group during 2012 
 
Warwickshire 
difficulties in registering with 
to identify at least one practice in 
 
(Gypsy and traveller health 
GPs 
each area which is willing to 
Esther Peapall 
meeting, autumn 2011) 
Research currently being 
register gypsy and traveller 
 
undertaken by Warwickshire 
families. 
 
LINk. A report will be 
 
available early 2012 
Patient Advice and Liaison Service 
team to work with Warwickshire 
County Council on outreach with 
the community 

 
2. Improved patient access and experience 
The NHS should improve accessibility and information, and deliver the right services that are targeted, useful, useable and used in order to improve patient experience 
2.1 Patients, carers and communities can readily access services, and should not be denied access on unreasonable grounds 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. NHS Coventry’s Commissioning 
Enquiries through Patient 
Ensure that all policies related to 
Undevelo
 
 
Caron Williams 
 
policies are not currently available 
Advice and Liaison Service 
how and why commissioning 
ped 
on the website 
regarding eg eligibility for 
decisions are made are available 
gastric band surgery 
on the website for the public to 
access 
b. NHS Warwickshire’s 
 
 
Achievin
 
 
Clive Compton 
 
Commissioning policies are 

currently available on the website 
A-Z of Clinical Policies and 
Procedures | NHS Warwickshire
 
c. Gypsies and travellers have 
Gypsies and travellers in 
Work with Gypsy and Traveller 
Developi
 
 
Kerrie Woods 
 
worse health than any other ethnic 
North Warwickshire report 
representatives, the Local Medical 
ng 
group leading to a shorter life 
difficulties in registering with 
Committees and Clinical 
expectancy 
GP practices 
Commissioning Groups to ensure 
Health needs of Gypsies and 
that all members of this population 
Travellers
have ready access to primary care 
 
services 
d. An options appraisal is currently 
PPI team is currently 
EIAs of the impact of the options 
Developi
 
 
Helen Bunter 
 
underway regarding maternity and 
undertaking engagement with  on the patients and the staff has 
ng 
paediatric services being provided 
local patients and residents. 
been carried out and will inform the 
by the George Elliot Hospital. 
Employee engagement will be  decision making process. 
undertaken as part of the 
process. 
http://www.coventrypct.nhs.uk
/GetInvolved/Consultations/M
aternity  

e. In Coventry, violent and 
Complaints have been 
Develop an Arden wide policy that 
Developi
 
 
Kerrie Woods 
 
aggressive patients are treated 
registered by the Patient 
will uphold patients’ right to a ‘fair 
ng 
within the Anchor Centre. There is 
Advice and Liaison Service by  trial’ 
no protocol in place for them to 
patients who do not feel that 
appeal the decision to remove them  they should still be on the 
from general practice and no 
V&A register 
process for them to be reviewed to 
 
determine whether they can return 
to general practice. NHS 
Warwickshire do have a process. 
f. Patients are removed from GP 
Complaints have been 
Work with the Local Medical 
Developi
 
 
Kerrie Woods 
 
lists with no right of appeal 
registered by the Patient 
Committees and Clinical 
ng  
http://www.rcgp.org.uk/PDF/Corp_r
Advice and Liaison Service 
Commissioning Groups to ensure 
emoval_of_patients_from_gp_lists1.
from patients 
that all practices have clear 
pdf  
policies in place regarding the 

removal of patients from lists and 
their right to appeal 
Re-issue guidance. 
Bench mark removals 
Possible inclusion in 1° Care 
Advisory Group.  
2.2 Patients are informed and supported to be as involved as they wish to be in their diagnoses and decisions about their care, and to exercise choice about treatments and places of treatment 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. Carers should be part of 
Carers groups report that 
Work with acute trusts to ensure 
Developi
 
 
 
 
discharge planning 
patient discharge from 
that carers are fully engaged. 
ng 
http://www.dh.gov.uk/prod_consum
hospital does not always 
Survey carers to receive qualitative 
_dh/groups/dh_digitalassets/@dh/
involve carers in decision 
feedback 
@en/@ps/documents/digitalasset/d
making. 
h_116675.pdf
http://static.carers.org/files/out
 
-of-hospital-final-report-6-
may-2010-5221.pdf
  
2.3 Patients and carers report positive experiences of their treatment and care outcomes and of being listened to and respected and of how their privacy and dignity is prioritised 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. Family members often complain 
With individual patients 
Patient consent is always sought 
Achievin
 
 
Rebecca Blyth 
 
on behalf of others. We need to 
and complaints cases do not 

ensure that the patient themselves 
proceed without consent. 
consents to the information being 
shared. The Complaints Policy is in 
place to cover this 
How to make a complaint | NHS 
Coventry
 
2.4 Patients’ and carers’ complaints about services, and subsequent claims for redress, should be handled respectfully and efficiently 
Data/information 
Engagement  
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. A feedback form is sent to 
From July 2010 – March 
Increase the response rate to at 
Achievin
  Rebecca 
Blyth 
 
Coventry complainants at the end of  2011, 44 forms were sent out 
least 40% 
g 
the process asking them about their  to those who had complained 
Maintain the % of positive 
experience of the complaints 
about Provider Services. 
responses to 90% 
process. A diversity monitoring form  There was a 34% return rate 
Address any issues raised through 
is included with this. 
(15 forms). Of these, 11 
internal processes 
(73%) were happy with the 
process and the way their 
complaint was dealt with 
(although not always content 
with the outcome 
During the same period, 29 
forms were sent to people 
who had complained about 
Commissioned Services. 10 

were returned (34%) with 
90% being happy with the 
way their complaint was 
processed  
b. NHS Warwickshire have not 
 Evaluation 
forms 
together 
with 
Undevelo
 
 
Rebecca Blyth 
 
carried out a similar process 
diversity questionnaire to be sent 
ped 
out to Warwickshire complainants 
during 2012 
3. Empowered, Engaged and Well-Supported Staff 
The NHS should Increase the diversity and quality of the working lives of the paid and non-paid workforce, supporting all staff to better respond to patients’ and communities’ 
needs
 
3.1 Recruitment and selection processes are fair, inclusive and transparent so that the workforce becomes as diverse as it can be within all occupations and grades 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. Six months of figures for 
Via Staff Engagement Forum 
An audit of a year’s worth of data 
Developi
  Helen 
Bunter 
 
recruitment/short listing and 
will be undertaken during 2012 
ng  
appointment data for Coventry PCT 
looking at all six protected 
(ie commissioning staff and 
characteristics collected by NHS 
Coventry Community Health 
Jobs 
Service) showed that some 
applicants were significantly less 
likely to be shortlisted than others. 
3.2 Levels of pay and related terms and conditions are fairly determined for all posts, with staff doing equal work and work rated as of equal value being entitled to equal pay 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. The gender pay gap in NHS 
Work is being undertaken via 
Run a focus group with female 
Undevelo
 
 
 
 
Coventry was at 15.72 % in 2010 
the Staff Engagement Forum 
employees at band 7 and ask them  ped 
and increased to 21% in 2011. 
about their aspirations 
Workforce Statistics | NHS Coventry
Have a female director talk to staff 
 
about work life balance and how 
they have progressed in their 
career. 
Monitor leavers via a form and a 
follow up phone call from HR in 
addition to the exit interview with 
the manager. 
Monitor the processes being used 
in re-configuration to ensure that it 
is fair and that senior women are 
not being disadvantaged. 
b. The gender pay gap in NHS 
 
Continue to monitor and report 
Achievin
 
 
Helen Bunter 
 
Warwickshire was 17.8% in 2010 
annually  

and decreased to -6.9% in 2011. 
Equality and Diversity | NHS 
Warwickshire
 

 
3.3 Through support, training, personal development and performance appraisal, staff are confident and competent to do their work, so that services are commissioned or provided appropriately 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. The 2010 staff survey reported 
Via Staff Engagement Forum 
Managers will receive training on 
Undevelo
 
 
 
 
that although 77% of staff at NHS 
conducting Individual Performance  ped 
Coventry had received an annual 
Reviews. 65% of managers will 
appraisal, only 36 % of staff said 
have been trained in Individual 
that it had been meaningful. Men 
Performance Review by April 
and disabled staff scored lower than 
2013. 
women and non-disabled staff 
Outcome: The staff survey for 
http://www.nhsstaffsurveys.com/NH
2012 to show an increase in the % 
SReports/NHS_staff_survey_2010_
of staff receiving an appraisal and 
5MD_sum.pdf
the % of staff who describe that 
 
appraisal as meaningful, with a 
greater increase being shown in 
men and disabled staff’s 
responses. 
b. The 2010 staff survey reported 
Via Staff Engagement Forum 
Managers will receive training on 
Undevelo
  Carol 
Innes 
 
that although 72% of staff at NHS 
conducting Individual Performance  ped 
Warwickshire had received an 
Reviews. 65% of managers will 
annual appraisal, only 35 % of staff 
have been trained in Individual 
said that it had been meaningful. 
Performance Review by April 
Men and disabled staff scored lower 
2013. 
than women and non-disabled staff 
Outcome: The staff survey for 
http://www.nhsstaffsurveys.com/NH
2012 to show an increase in the % 
SReports/NHS_staff_survey_2010_
of staff receiving an appraisal and 
5PM_sum.pdf
the % of staff who describe that 
 
appraisal as meaningful, with a 
greater increase being shown in 
men and disabled staff’s 
responses. 
3.4 Staff are free from abuse, harassment, bullying, violence from both patients and their relatives and colleagues, with redress being open and fair to all 
Data/information 
Engagement 
 
RAG rating 
Lead 
Evidence 
Jan 2012 
 
 
a. The 2010 staff survey for NHS 
The staff stress survey 
The Head of Equality and Human 
Undevelo
 
 
 
 
Warwickshire reported that  
carried out in 2011 showed 
Rights will invite disabled staff to 
ped 
disabled staff were more than twice 
that disabled staff were more 
confidential 1-2-1 meetings to 
as likely to report work related 
likely to report bullying and 
discuss the issue with them. 
stress, and bullying or harassment  
higher rates of stress than 
During Individual Performance 
by other staff, than non-disabled 
other staff 
Reviews staff will be asked if any 
staff  
accommodation needs to be made 
http://www.nhsstaffsurveys.com/NH
for any disability or condition that 
SReports/NHS_staff_survey_2010_
they have. 
5PM_sum.pdf
The issues will be discussed via 
 
the Staff Engagement Group 

 
b. The 2010 staff survey for NHS 
The staff stress survey 
The Head of Equality and Human 
Undevelo
  Helen 
Bunter 
 
Coventry reported that  disabled 
carried out in 2011 showed 
Rights will invite disabled staff to 
ped 
 
staff were more than twice as likely 
that disabled staff were more 
confidential 1-2-1 meetings to 
 
to report  bullying or harassment  by  likely to report bullying and 
discuss the issue with them. 
 
other staff than non-disabled staff  
higher rates of stress than 
During Individual Performance 
Carol Innes 
http://www.nhsstaffsurveys.com/NH
other staff 
Reviews staff will be asked if any 
SReports/NHS_staff_survey_2010_
accommodation needs to be made 
5MD_sum.pdf
for any disability or condition that 
 
they have. 
The issues will be discussed via 
the Staff Engagement Group 
c. Staff working in complaints, 
Discussions have been held 
Re-do risk assessment.  
Developi
 
 
Carol Innes  
 
Patient Advice and Liaison Service 
with staff involved 
Revisit policy. 
ng 
and Individual Funding Request 
Consider building in counselling 
services are sometimes verbally 
support every 2 weeks by 
abused by patients and can feel 
telephone for affected staff 
physically under threat during face 
Recording of all telephone 
to face meetings. A policy is in 
conversation received to these 
place to help staff to deal with 
phone lines 
vexatious patients. Staff have been 
given conflict resolution training. A 
risk assessment was carried out  
3.5 Flexible working options are made available to all staff, consistent with the needs of the service, and the way that people lead their lives. (Flexible working may be a reasonable adjustment for 
disabled members of staff or carers.) 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. The 2010 staff survey for NHS 
Via Staff Engagement Forum 
During 2012, staff will be reminded  Undevelo
 
 
 
 
Coventry reported that 78% of staff 
of their right to request flexible 
ped 
used flexible working. This was 
working via information on the 
worse than similar trusts 
intranet and through an article in 
http://www.nhsstaffsurveys.com/NH
Evolution Magazine 
SReports/NHS_staff_survey_2010_
5MD_sum.pdf 
b. The 2010 staff survey for NHS 
 
 
Achievin
 
 
Carol Innes 
 
Warwickshire reported that 88% of 

staff used flexible working. This was 
better than similar trusts 
http://www.nhsstaffsurveys.com/NH
SReports/NHS_staff_survey_2010_
5PM_sum.pdf
 

 
3.6 The workforce is supported to remain healthy, with a focus on addressing major health and lifestyle issues that affect individual staff and the wider population 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence  
Jan 2012 
 
 
a. The Invest in You programme 
Evaluation of  the programme  Development of the programme 
Achievin
 
 
Carol Innes 
 
has been developed to increase the  shows that staff have 
g  
resilience of staff in the face of 
received the programme very 
change 
positively 
b. A telephone support system – 
Feedback from staff who 
Continue to provide. 
Achievin
  Carol 
Innes 
 
Employee Assistance Programme –  have used the service is very 
g 
is in place 
positive  
www.employeeassistance.org.uk 
c. A contract is in place with the 
Through Staff Side and Joint 
Continue to provide. 
Achievin
 
 
Carol Innes 
 
occupational health service to 
Negotiating and Consultative 

support staff via physiotherapy, 
Committee 
workplace assessment, long term 
sickness and return to work, referral 
to counselling services 
4 Inclusive leadership at all levels 
NHS organisations should ensure that equality is everyone’s business, and everyone is expected to take an active part, supported by the work of specialist equality leaders and 
champions
 
4.1 Boards and senior leaders conduct and plan their business so that equality is advanced, and good relations fostered, within their organisations and beyond 
Data/information 
Engagement 
Action 
RAG rating 
Lead 
Evidence 
Jan 2012 
 
 
a. The Cluster Board wants to keep 
Patients and carers are 
A patient or carer tells their story at  Developi
 
 
Fay Baillie 
 
a focus on the health and treatment 
engaged with to select 
the beginning of every Board 
ng 
of patients in all their decisions 
volunteers. 
meeting 
b. The Cluster Board has requested  Discussions with senior 
To be included as part of the 
Undevelo
 
 
Helen Bunter 
 
that they are updated at every 
directors 
Director of Nursing’s Board report 
ped 
meeting regarding exceptions to 
this action plan 
c. At Board meetings, equality and 
Discussions with senior 
In conjunction with the NHS 
Developi
 
 
Fay Baillie 
 
human rights should be part of core 
directors and previous Board 
National Leadership Council, 
ng 
business 
training 
senior members of the Board will 
be coached and given feedback to 
support them in this work 
d. Commissioning Support Service 
 
Raise at senior team meeting to 
Undevelo
 
 
Caron Williams 
 
is a new organisation and is still 
add to personal development plans
ped  
developing 
e. Transfer of commissioning 
Training and support 
To carry out an equality impact 
Undevelo
 
 
Juliet Hancox 
 
responsibilities from PCTs to 
available to Clinical 
assessment of our Clinical 
ped  
Clinical Commissioning Groups 
Commissioning Groups 
Commissioning Group 
during 2011 – 2012 include public 
commissioning strategies 
body duties under the Equality Act 
2010 
http://www.nhsemployers.org/SiteC

ollectionDocuments/Implementing%
20the%20Equality%20Act%202010
%20-
%20Interim%20guidance%2028.11.
2011.pdf 
4.2 Middle managers and other line managers support and motivate their staff to work in culturally competent ways within a work environment free from 
 
discrimination 
Data/information 
Engagement  
Action 
RAG rating 
Lead 
Evidence 
Jan 2012 
 
 
a. The 2010 staff survey reported 
Staff survey feedback 
Training to be provided for 
Undevelo
  Carol 
Innes 
 
that although approximately 70% of 
managers to improve the content 
ped 
staff had received an annual 
of annual appraisals.  This will 
appraisal, only half of these said 
include how to support disabled 
that it had been meaningful. Men 
staff by offering them the 
and disabled staff scored lower than 
opportunity to discuss any issues 
women and non-disabled staff 
that they may have. 
4.3 The organisation uses the “Competency Framework for Equality and Diversity Leadership” to recruit, develop and support strategic leaders to advance 
 
equality outcomes 
Data/information 
Engagement  
Action 
RAG rating 
Lead 
Evidence 
Jan 2012 
 
 
a. Commissioning Support Service 
Via Joint Negotiating and 
Raise at senior team meeting to 
Undevelo
 
 
Caron Williams 
 
is a new organisation and is still 
Consultative Committee and 
add to personal development plans
ped  
developing 
Staff Side have a seat on the 
steering group 
b. As part of their authorisation 
Training and support 
To evidence use of the national 
Undevelo
 
 
Juliet Hancox 
 
process, Clinical Commissioning 
available to Clinical 
competency framework for equality  ped  
Groups are required to evidence 
Commissioning Groups 
and diversity leadership in the 
that they are able to comply with 
development of our individual 
their public body duties under the 
Clinical Commissioning Group 
Equality Act 2010 
boards 
http://www.yorksandhumber.nhs.uk/
document.php?o=7480