This is an HTML version of an attachment to the Freedom of Information request 'Francis report'.

7.2 
LOTHIAN NHS BOARD 
 
Board Meeting 
24 March 2010 
 
Nurse Director 
 
 
 
STRENGTHENING EQUALITY AND MUTUALITY GOVERNANCE 
 
 
1  
Purpose of the Report 
 
1.1 
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. 
 
2 Recommendations 
 
 Lothian NHS Board is invited to: 
 
2.1 
Agree to the establishment of a Mutuality & Equality Governance Committee.  
 
 
3  
Summary of the issues 
 
3.1 
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 
Strategy. 
  
3.2 
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 
(2007). 
•  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 
Spiritual Care 
−  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 
 commissioners 
 
•  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. 
 
3.3 
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. 
 
3.4 
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 
structures. 
 
3.5 
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. 
 
3.6 
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. 
 
3.7 
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. 
 
3.8 
The committee should be named the Mutuality & Equality Governance Committee. 
 
3.9 
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 
membership includes: 
•  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 
Commission. 
 
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 
 
4.1 
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.  
 
 
5 Resource 
Implications 
 
5.1 
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  
 
           Committee 
Appendix 2:  Proposed Mutuality & Equality Governance Committee reporting  
 
  arrangements 
 
 


 
 
 
 
APPENDIX 1 
 
Mutuality & Equality Governance Committee 
 
Terms of Reference  
 
Remit: 
 
•  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 
Scottish Government 
 
•  Assure the delivery of Board strategies to promote this agenda and give 
direction to future strategy. 
 
 
Membership: 
 
•  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. 
 
Quorum: 
 
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. 
 
 
 
 
 
 
 


APPENDIX 2 
 
Comparison of reporting arrangements for Mutuality and Equality Governance Committee with previous structure 
 
Proposed Mutuality and Equality Governance Committee reporting arrangements 
 
NHS Lothian Board 
 
 
Reporting to 
 
 
Staff 
Mutuality & 
Healthcare 
 
Governance 
Equality 
Governance & 
 
 
 
Committee 
Minutes to 
 
 
 
 
 
Governance 
 
 
 
Minutes to    
Risk 
 
Committee
Management 
 
Committee 
 
                                                                                              Responsible for 
 
 
Improving 
 
Involving 
Equality & Diversity 
Spiritual Care & 
Patient 
 
People 
Management Group 
Bereavement 
Experience 
 
Management 
Management 
Group
 
Group 
Group
 
 
•  UHD Equality & 
•  Faith & Belief 
 Advocacy, 
Diversity 
Forum
•  Clinical Information for 
 
Volunteering, 
Implementation Group 
Patients Group 
 
Carers 
•  Equity Audit Core 
• Patient 
Experience 
 
Strategies 
Group  
 
Cancer Pilot 
•  EQIA Steering Group  
 
• Human 
Resources 
 
Equality & Diversity 
Previous reporting arrangements 
Sub Group


 
 
 
NHS Lothian Board 
 
 
 
 
 
 
Healthcare 
Staff 
Spiritual Care 
 
Governance & 
Governance 
Committee 
 
Risk 
Committee 
 
Management 
 
Committee 
 
                    Minutes to 
                   Reporting to 
 
 
Minutes to 
 
Equality & 
 
Involving 
Diversity 
 
People  
Steering  
 
Group 
Group
 
 
 
 
Responsible for 
 
Agenda 
 
 
 
Agenda 
Agenda 
Spiritual Care 
 
Involving People 
Equality & 
Mutuality 
Diversity  
Strategy