LOTHIAN NHS BOARD
24 March 2010
STRENGTHENING EQUALITY AND MUTUALITY GOVERNANCE
Purpose of the Report
To propose a replacement committee to take over the remits of the Equality and
Diversity Steering Group and the Spiritual Care Committee, in the light of the
recent Board decision to merge the two committees and the Board’s approval of
the Involving People – Improving People’s Experience of Care Strategy.
Lothian NHS Board is invited to:
Agree to the establishment of a Mutuality & Equality Governance Committee.
Summary of the issues
At its meeting in May 2009, the Board agreed to merge the Equality and Diversity
Steering Group and the Spiritual Care Committee. At its July 2009 meeting, the
Board approved the Involving People – Improving People’s Experience of Care
The Board requires a governance structure to:
• Oversee work to ensure that NHS Lothian meets its existing equality & diversity
duties, such as the delivery of the NHS Lothian Equality & Diversity Strategy
• Oversee work that will ensure that the likely requirements of forthcoming
equality & diversity legislation are met, such as the Single Equality Duty arising
from the Equality Bill 2009.
• Oversee work to ensure that NHS Lothian meets its legal duties set out in the
NHS Reform (Scotland) Act 2004, Section 7, and other related legislation
regarding major service change;
• Ensures implementation of the following key Chief Executive Letters (CELs):
- CEL (2010) 04
Informing, Engaging, Consulting People in Developing
Health and Community Care Services
− CEL (2008) 49
− CEL (2008) 10
Refreshed Strategy for Volunteering in
the NHS in Scotland
− HDL (2006) 22
NHS Carer Information Strategies
− HDL (2001) 08
Independent Advocacy: A guide for
• Has regard to existing Human Rights and new patients rights legislation.
• Oversee and monitor implementation of the Framework for Mutuality:-Involving
People – Improving People’s Experiences of Care Strategy (2009-2013)
Involving People Component.
The Participation Standard to be introduced by the Scottish Government in 2010-
11 requires NHS Boards to integrate the level and quality of participation into NHS
Scotland’s overall approach to quality improvement and performance
management. This will ensure that patient focus and public involvement are core
drivers of decision making and not an after thought or side issue. NHS Boards will
be asked to audit against this standard in order to collect systematic, comparable
information on good practice, in a similar way to the NHS Quality Improvement
Scotland Clinical Governance & Risk Management standards. The standard has
three core elements, one of which is corporate governance of participation. This
core element states: robust corporate governance arrangements are in place for
involving people, founded on mutuality, equality, diversity and human rights
principles. This requires evidence that Boards are able to demonstrate leadership
of this agenda and that the public are inputting to Board Committees.
Other NHS Boards in Scotland have a mixture of committee structures. Some like
NHS Greater Glasgow & Clyde and NHS Borders have separate reporting
committees for patient focus and public involvement. Others like NHS Highland
and NHS Tayside have one committee for this agenda (including equality and
diversity and clinical governance), but have commented that with the increasing
complexity and widening of this agenda they are considering reviewing their
This paper suggests how a committee combining the above responsibilities might
work and what the timescales might be to establish it. The committee should be
developed at the Board Committee level, reporting directly to the Board. This will
ensure that the Board not only receives the assurance that this important agenda
is being addressed, but it will also demonstrate the Board’s leadership.
The delivery of strategies to meet the above responsibilities remains the role of
executive management, through established NHS Lothian delivery and
performance management systems. It is not the function of the replacement
committee to duplicate these systems, or absolve line managers of their own
responsibilities by taking ownership of this role. For example new management
arrangements have been put in place for the Spiritual Care Service as agreed by
the Spiritual Care Committee.
A remit at Appendix 1 reflects the strategic level of the committee. This remit
should provide a corporate focus and ensure the Board of the governance,
accountability and delivery of these important duties. It is proposed that the terms
of reference of this committee are considered at the first meeting and
strengthened and expanded appropriately.
The committee should be named the Mutuality & Equality Governance Committee.
Membership for the committee should reflect its more strategic level than existing
structures. It will be important to ensure that representatives communicate
effectively with their respective parts of the organisation. It is suggested that
• At least three non-Executive members of the Board (with one in the Chair)
• At least 3 executive members (potentially Director of Human Resources, Nurse
Director, Director of Public Health)
• Others in attendance to represent leads in Equality and Diversity, Involving
People, Spiritual Care and Bereavement and service management
• Staff Partnership and public representation (x4 each)
3.9.1 The Lothian NHS Board Chair has invited Julie McDowell to chair the committee.
3.10 The membership of the committee would be approximately half that of the current
Equality & Diversity Steering Group. Other individuals may be invited to attend as
necessary for the agenda of a particular meeting, and there may be
representatives of key partner agencies such as NHS Health Scotland’s Equalities
& Planning Directorate in attendance.
3.11 Reporting arrangements will include submission of minutes from all meetings to
the Board, along with a regular (once or twice annually) progress report on the key
strategies listed above (and any other deemed relevant by the committee), and an
annual report on the work of the committee itself. Minutes will also be passed to
the Healthcare Governance & Risk Management Committee and the Staff
Governance Committee (see Appendix 1 and 2).
3.12 The committee should have its first meeting in May 2010, after a final meeting of
the Equality & Diversity Steering Group in March 2010. The Spiritual Care
Committee has ceased to operate as a distinct structure.
3.13 The remit of the Healthcare Governance & Risk Management Committee would
retain responsibilities for a Framework of Mutuality - Involving People, Improving
People’s Experience of Care Strategy, specifically the 5 commitments related to
improving patient experience. This would continue to include all aspects of
monitoring and continually improving person-centred care in NHS Lothian. This
will fit with the new national NHS Scotland Quality strategy.
3.14 The Committee would assure the Board of delivery against legal duties as
scrutinised by the Scottish Health Council and the Equality and Human Rights
3.15 The Staff Governance Committee will retain the governance of all duties on the
Board in relation to employee rights and employer duties.
Impact on Health Inequalities
The structure proposed will ensure effective governance of the key areas of work
listed above. Each programme will be subject to equality impact assessment to
identify positive and negative equality impacts, and recommendations to address
these. The work will also include activities to promote equality impact assessment
and health impact assessment across all NHS Lothian departments and functions,
and the development of legal and other evaluatory tools to review corporate
governance of equality. The committee will ensure that NHS Lothian meets its
statutory responsibilities in respect of equality & diversity and will therefore have a
positive impact on health inequality.
There are no adverse resource implications arising from this paper.
Pat Dawson, Associate Nurse Director (Strategic Development)
James Glover, Head of Equality and Diversity
12 March 2010 List of Appendices
Appendix 1: Terms of Reference and Remit for the Mutuality & Equality Governance
Appendix 2: Proposed Mutuality & Equality Governance Committee reporting
Mutuality & Equality Governance Committee
Terms of Reference
• Provide leadership and agree the strategic direction to develop and deliver
mutuality, equality and diversity and spiritual care, and pay due regard to
Human Rights Legislation.
• Ensure implementation of the relevant directives and other instruction from the
• Assure the delivery of Board strategies to promote this agenda and give
direction to future strategy.
• As set out in paragraph 3.9
Frequency of Meetings:
Meetings of the Committee shall be held at such intervals as the Committee may
determine in order to conduct its business. In any event, meetings shall normally be held
four times a year.
No business shall be transacted at a meeting of the Committee, unless at least two Non-
Executive Board members are present. Any Non-Executive Board Member may deputise
for a member of the Committee at any meetings. Reporting Arrangements:
The Committee will report to the Board by means of submission of minutes to the next
available Board meeting.
Comparison of reporting arrangements for Mutuality and Equality Governance Committee with previous structure
Proposed Mutuality and Equality Governance Committee reporting arrangements
NHS Lothian Board
Equality & Diversity
Spiritual Care &
• UHD Equality &
• Faith & Belief
• Clinical Information for
• Equity Audit Core
• EQIA Steering Group
Equality & Diversity
Previous reporting arrangements
NHS Lothian Board