Implementation of the Equality Delivery System – EDS2 is a requirement on both NHS commissioners and NHS providers. Organisations are encouraged to follow the implementation of EDS2 in accordance with the ‘9 Steps for EDS2 Implementation’ as outlined in the 2013 EDS2 guidance document.

This EDS2 Summary Report is designed to give an overview of the organisation’s most recent EDS2 implementation. It is recommended that once completed, this Summary Report is published on the organisation’s website.

NHS organisation name: Lancashire and South Cumbria NHS Foundation Trust

Organisation’s Board lead for EDS2: Robert Cragg, Chief People Officer

Organisation’s EDS2 lead (name/email): Candace Bedu-Mensah (candace.bedu-mensah@lscft.nhs.uk)

Level of stakeholder involvement in EDS2 grading and subsequent actions: The COVID 19 and the Black Lives Matter movement held a spotlight on the inequalities, inequity and disparities with the Trust. It was recognised that there can no longer be a delay to take action to improve the lives of citizens, patients, and colleagues.

An EDS2 event was held virtually and the link was circulated to the workforce, community partners, citizens and service users. A discussion was facilitated by leaders and then support was given in breakout rooms in relation to scoring.

Organisation’s Equality Objectives (including duration period): 

  1. We will put SERVICE users at the heart of everything we do, supporting effective care, recovery and wellbeing
  2. We will employ and retain the best STAFF because our work culture will be inclusive and a supportive place to work
  3. We will deliver SAFE care and we will embrace an open and learning culture, ensuring we continually improve
  4. We will respond to peoples needs by striving for the highest STANDARDS of quality, proactively reducing health inequalities

Headline good practice examples of EDS2 outcomes (for patients/community/workforce):  Lancashire and South Cumbria Foundation Trust was recently nominated for and shortlisted for an HSJ award under the category inspiring culture change through Inclusive Engagement. This is a great testament to the commitment that the Trust has made to improving the disparities across the Trust and within local communities.

The Trust is now on the journey of dealing with the root causes of health inequalities and inequity. This journey includes the Trust being transparent and open ourselves up to scrutiny from Community partners, service users and members of the public.

EDS 2 grading

Date of grading: May 2022

Goal: Better health outcomes

Grade: developing

Which characteristics fare well?

  • pregnancy and maternity
  • race
  • religion or belief

Evidence drawn upon for rating: COVID 19 removed the veil of ignorance and drew health inequalities and inequities into the spotlight. The Trust has taken bold and purposeful steps to look at how we are investing in suppliers and we are assessing the equality impact of services.

Deciding how we spend our money is very important, ensuring that our budget is spent in the right places. The Trust has a duty of care to ensure that any suppliers that we engage with prioritise inclusion and actively take steps to improve inequalities. The Trust also does what it can to invest in our local communities by using local suppliers where possible. 

After a recent review of the Equality Impact Assessment process revealed that community engagement was poor. This process has now been revised and includes robust training and clear communication links to community partners for meaningful engagement to influence.   

Outcome links to an equality objective: Yes

Grade: developing

Which characteristics fare well?

  • pregnancy and maternity
  • race
  • age
  • sex
  • disability

Evidence drawn upon for rating: Not measured as part of this year's report.

Outcome links to an equality objective: Yes

Grade: achieving 

Which characteristics fare well?

  • pregnancy and maternity
  • race
  • age
  • religion or belief 
  • disability

Evidence drawn upon for rating: Not measured as part of this year's report.

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: Not measured as part of this year's report.

Grade: developing

Evidence drawn upon for rating: COVID 19 really opened the eyes of the Trust about how we work collaboratively with communities and across services for health promotion. Using a multi-disciplinary approach teams where coordinated to ensure that we look at bridging the gap in health inequalities to ensure maximum uptake of the vaccine and screening opportunities.

Examples of the work done are Webinars with community and faith leaders, use of the HARRI bus to contact local communities, Engagement with community groups to discuss health promotion and the barriers to influence process, attending community events to network with the locals and deliver face to face health promotion.
 
We learnt to better communicate internally for the benefit of the community ensuring a streamlined approach to health promotion.

Outcome links to an equality objective: Yes

Goal: Improved patient access and experience

Grade: excelling

Which characteristics fare well?

  • pregnancy and maternity
  • race
  • age
  • sex
  • disability
  • marriage and civil partnership 
  • religion or belief
  • sexual orientation

Evidence drawn upon for rating: Not measured as part of this year's report.

Outcome links to an equality objective: Yes

Grade: achieving 

Which characteristics fare well?

  • pregnancy and maternity
  • religion or belief
  • age
  • sex
  • disability
  • sexual orientation 

Evidence drawn upon for rating: Not measured as part of this year's report.

Outcome links to an equality objective: Yes

Grade: achieving

Which characteristics fare well?

  • race

Evidence drawn upon for rating: Not measured as part of this year's report.

Goal: A represented and supported workforce

Grade: developing

Evidence drawn upon for rating: Recruitment is highlighted as a high-level risk for the organisation and consequently a lot of work has been done to mitigate the risk and remove bias for the recruitment and selection process.

We have implemented a toolkit for recruiting managers which highlights the standard that the Trust follows to recruit. The toolkit has been informed by the staff voice, research and NHS best practice. The toolkit includes basic level training on Unconscious bias, cultural awareness and how to implement reasonable adjustments. The toolkit has also implemented the use of diverse interview panels, questions based on inclusion, support for candidates to navigate the process and providing time to review interview questions.

As part the Trust change program Listening into Action a recruitment work stream was created to amend the recruitment selection process based on feedback from the community and the wider workforce. This work stream also works with the ED&I team to ensure that the toolkit remains relevant and up to date.

We have also just had an external review based on our recruitment and how we attract applicants to the Trust. This independent review looked at how we attract applicants and how we can make adverts more inclusive and attract more people from local communities.

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: The Trust is now in the process of developing our Gender Pay Gap report. The call to action that the Trust received in line with COVID, Black Lives Matter and health inequalities. Brought with it the need to move away from conventional reporting and following base line metrics. The Trust is now looking at how we can advance the Gender Pay Gap report that we are required to complete annually to declare the pay gap between males and females. We are now looking at the data through an intersectional lens to understand how someone's background, religion, gender or sexual orientation can effect their pay and their career progression. 

In connection to this report any trends or correlations that highlight inequalities will be investigated and actions will be highlighted in strategic plan which are fed into by the Trusts staff networks. This ensures that any change is led by the people instead of for them.

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: There is data available across the NHS which highlights that certain staff groups find it harder to access training and development opportunities. Unfortunately, LSCft is no exception to this trend. We are very pleased to say that recent reports have shown that a proportion of our staff believe that LSCft offer fair career opportunities and we have also been named in the Workforce Race Equality Standards for our consistent improvement in regards to staff from a BME background accessing training and development opportunities. Collaborative working and engagement have been instrumental to this success. The OD team, ED&I team, Medical workforce and Nursing Directorate have been working closely together to look at what opportunities are available, how they are promoted and if they are having an impact. There has also been continuous evaluation to understand how courses have been received, did they support the individuals progression, did they face an barriers to access these opportunities. The answers allow us to continually improve our opportunities and practices.

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: The Trust data clearly tells us that there is a disparity of experiences across our workforce in relation to diversity. However, our data overall does show that across the entire workforce we need to considerably improve the experiences of all staff.

The Inclusion which is chaired by our CEO has now launched a series of work streams dedicated at dealing with key themes that need to change to make LSCft truly inclusive. One of these work streams is concentrating on Bullying and Harassment. The work stream has three priority objectives, leadership training on Bullying and Harassment, Policy for Bullying and Harassment which incorporates just culture, civility and zero tolerance and a collection of intelligence on Bullying and Harassment with the Trust.

Alongside these the ED&I team have been working with HR and the Freedom To Speak Up function to look at how we are dealing with cases in relation to protected characteristics to embed some uniformity to how these cases are handled to ensure an inclusive and holistic process. The process also will help identify repetition and highlight hotspots within the organisation. 

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: The same as across the NHS the pandemic has made the Trust think differently about flexible working and how we better support staff. The Trust Launched a change program called Listening into Action which had a dedicated work stream based on Flexible working. This work stream was lead by the voice of the people and out of this we now have a dedicated flexible working policy which reflects the needs of the workforce.

We have also now launched a reasonable adjustment policy which was designed in collaboration with the Union, ED&I team, Staff Networks (lead by the Disability and Long Term Conditions Network) and local community leaders. This policy also includes disability leave which is new to the Trust.

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: The staff survey, Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) data has highlighted that since the Trust has been on its Inclusion Journey staff have felt more supported and we have seen increased levels of engagement. However, the Trust is yet to close the gap between the disparities and is far from the end of the journey.

There has been considerable work gone into improving the support functions across the Trust. We now have seven established staff networks (Race Equality, LGBTQ+, Women's, Disability and Long Term Conditions, International, ED&I Champions) which report directly into the Inclusion Council to influence Trust decisions. All Equality Impact Assessments need to evidence how they have engaged with these networks and the wider community. This also includes evidence o show that their voice has been reflected in any changes.

Outcome links to an equality objective: Yes

Goal: Inclusive leadership

Grade: developing

Evidence drawn upon for rating:  The Trust has recently undergone an independent Race Equality Review which was commissioned by our Chief Executive. The actions which came out of this review include a theme which covers Board and senior leadership.

The actions highlighted are all due to be completed September 2022, sustainability is built into these actions to ensure continuity. The plan includes activities such as reverse mentoring, each board member to have an inclusion objective, Board development plan and exposure to staff and service user stories.

The inclusion Council which is chaired by our CEO holds the Trust to account for achieving our Inclusion objectives and for taking action to reduce the inequalities and disparities identified in our annual reporting. The next steps for the Trust include an independent review looking at disability.

Outcome links to an equality objective: Yes

Grade: developing

Which characteristics fare well?

  • race
  • age
  • sex
  • disability
  • religion or belief
  • sexual orientation 

Evidence drawn upon for rating: All Papers which are presented to Board have a front sheet that clearly indicates which Trust risks the paper relates to and any equality impact. All papers need to indicate how they are planning to mitigate any risks and remove any barriers in relation to equality.

Outcome links to an equality objective: Yes

Grade: developing

Evidence drawn upon for rating: COVID 19, the Black Lives Matter movement and the call to action by the NHS long term plan where all catalysts to make LSCFft hold the mirror up to itself and see the lived realities of our workforce. 

This work was about taking what we know through staff survey, WRES and WDES, working with staff networks to understand what is happening to our staff and using the staff voice to influence out strategic plans which drive change.

The Trust has hosted the Kings Fund project concentrating on leadership development, we have implemented our leadership prospectus and have clear communication with staff networks to understand the reality of staff to better inform any development.

Outcome links to an equality objective: Yes


You can download a PDF copy of the EDS2 Report but please note that it does not meet accessibility standards.