EDS Report 2024-25

Background

The main purpose of the Equality Delivery System (EDS) is to help local NHS organisations, in discussion with local partners including local people, review and improve their performance for people with characteristics protected by the Equality Act 2010.  By using EDS, NHS organisations can also be helped to deliver on the public sector Equality Duty (PSED).

Essentially, there is just one factor for NHS organisations to focus on with the grading process.  For most outcomes the key question is: how well do people from protected groups fare compared to people overall?  There are four grades – Undeveloped, Developing, Achieving, and Excelling.

The EDS provides a way for the organisation to show how it is doing against the three domains:

Domain 1: Commissioned or Provided Services – This focuses on patient access and experience, reducing inequalities and enabling better health outcomes.

Domain 2: Workforce Health & Wellbeing – This focuses on ensuring that all workforce members are fully supported in relation to health and wellbeing.

Domain 3: Inclusive Leadership – This domain explores how leadership at WMAS demonstrates a commitment to equality and how it works in a way that identifies equality issues and manages them.

Each of the above domains has set outcomes that are evaluated and scored against the set criteria, and experiences of stakeholders. It is these ratings that provide assurance and/or provide direction for further improvement.

The purpose of this report is to:

• Summarise the Trust process undertaken to deliver on the EDS for this reporting year.
• Report on the EDS ratings that have been achieved, along with stakeholder feedback.
• Outline actions that will be taken to improve on EDS ratings.

All NHS organisations are expected to use the system to help them improve their equality performance for patients, communities and staff, as well as help them to meet the requirements of the PSED.

Brief overview of the Trust

WMAS was formed in 2006 bringing four previous services together. In January 2013 WMAS were authorised as a Foundation Trust and in line with the Health and Social Care Act 2012, was licensed to provide services on 1^st April 2013.  As a Foundation Trust WMAS must have a constitution that is compliant with the current statute and the regulators code of conduct for Governance. More information can be found on the WMAS website www.wmas.nhs.uk

WMAS serves a population of 5.6 million people covering more than 5,000 square miles, which is made up of Shropshire, Staffordshire, Herefordshire, Worcestershire, Coventry, Warwickshire, Birmingham, and Black Country conurbation.  

As the region’s emergency ambulance service, WMAS respond to around 3,000 999 calls each day. To manage that level of demand WMAS employ over 7,000 staff to operate from 16 fleet preparation hubs across the region. WMAS also provide non-emergency patient transport services across parts of the region for patients that require non-emergency transport to and from hospital and who are unable to travel unaided because of their medical condition or clinical need.  WMAS completes approximately 700,000 non-emergency patient journeys each year.

Equality, Delivery System (EDS) Key Information

• Organisation – West Midlands Ambulance Service
• Organisation Board Sponsors – Director of People
• Integrated Care System – Black Country ICS
• EDS Lead – Mohammed Ramzan
• Domain 1 Lead – Mohammed Ramzan (EDI Lead)
• Domain 2 Lead – Mohammed Ramzan (EDI Lead)
• Domain 3 Lead – Mohammed Ramzan (EDI Lead)
• Domain 1 Engagement Dates – 18/12/24; (Online – Teams) 27^th January to 31^st January 2025
• Domain 2 Engagement Dates – 27^th January to 31^st January 2025
• Domain 3 Engagement Dates – 27^th January to 31^st January 2025
• Date Completed – 31^st January 2025
• Month and Year Published – February 2025
• Date Authorised – TBC
• Revision Date – TBC

Equality Delivery System Rating and Score Card Overview

Trust Approach to EDS Implementation

For 2024/25 reporting year all three Domains of the EDS have been assessed.

An EDS working group has been developed to oversee Trust implementation.  The group members consist of the following stakeholders: EDI and Well-being Team, OD, HR, Staff Network Leads, and Staff Side/Trade Union representatives.

Under Domain 1, it was agreed to focus on one service area focusing on Patient Transport Service for 2024-25, a method which has worked well for WMAS in the past couple of years. 

At WMAS, the EDS framework is utilised so meaningful, positive and transformational change can take place with tangible improvements and services chosen will be revisited, if appropriate, every two years. At WMAS we have taken a more pragmatic approach in the utilisation of the EDS3 framework. The work does not stop at the conclusion of the assessment and grading phase.  The reports are presented, and action plans developed which are then monitored at the Diversity, and Inclusion Steering Group (DISAG).

A separate evidence pack was compiled for each Domain.  Compilation of evidence packs largely utilised already existing data and reports.  Service leads were contacted where required to provide specific input on their service.  Stakeholder grading sessions were conducted over Microsoft Teams or remotely due to winter pressures and the adverse weather.  Participants were asked to provide a score of 0, 1, 2, or 3 against each outcome, using the EDS Ratings and Scorecard Guidance 2022.

Finally, the grading assessment at WMAS acknowledges areas of work which are achieving and doing really well whilst identifying gaps and service improvements.

Doman 1: Commissioned or Provided Services

The NHS Equality Delivery System 3 provides a way for the organisation to show how it is performing against the three Domains.  For the purposes of this section, it is Domain 1 that has been assessed.

Agreed scores for all areas of the Domain (if applicable as not all outcomes will be readily applicable to all service areas in the Ambulance service).

• 1A: 1
• 1B: 1
• 1C: 1
• 1D: 1
• Collective grade for Domain 1 (only for PTS service: is DEVELOPING).
• DEVELOPING Score = 4

In 2024/25, for Domain 1, WMAS undertook assessment of the Patient Transport Service, as a provided service.   Each year, we aim to address one service for Domain 1 so a more meaningful assessment can take place with tangible medium to long-term outcomes.  There are several benefits with this approach as follows:

1. Assessments are not rushed, and a more qualitative and in-depth analysis takes place which results in actions to improve the service.
2. Assessors are not over-burdened with information and assessments are not rushed.
3. Setting realistic goals and action plans which lead to transformational change
4. Making EDS3 work as a tool to effect organisational change, as it was originally intended, as opposed to a tick box exercise.

Background and Evidence: Patient Transport Service at WMAS – A Case study

The Patient Transport Service (PTS) has a key role to play in supporting the delivery of high-quality patient care whilst ensuring value for money is achieved. The demands on the PTS and expectations of the efficiencies required are increasing, and the Trust is continuing to respond to these challenges. Non-emergency patient transport – As well as dealing with 999 emergency calls, we play a key role in getting hundreds of thousands of patients to and from their hospital appointments.

About our Patient Transport Service

We are proud to operate seven non-emergency patient transport service contracts within the West Midlands and Cheshire to ensure patients get to and from their hospital appointments. As well as covering the region, our crews can end up in any part of the UK, 24 hours a day, seven days a week. As a Service we have vast experience of running PTS operations and successfully meeting our key performance indicators (KPIs) by being able to show that we can cater for each individual patient’s needs.  

Our PTS staff, book and transport, eligible patients to hospital appointments, transfer between hospital sites, deal with routine admissions, discharges and provide transport for patients undergoing continuing treatments such as renal dialysis and oncology. We also provide journeys for patients with more complex medical needs including those who are bariatric, high dependency and at the end of life. We take bookings based on the criteria set by our commissioners.  

Our staff

We employ around 900 highly experienced and dedicated PTS staff across our contracts who deal with just under 1 million patient journeys every single year clocking up more than 6 million miles!  Our PTS staff work operationally from 11 bases and four control rooms. Every patient journey we provide is booked and co-ordinated by our dedicated control room staff who are based in our Stafford, Coventry, Warrington and Frankley control rooms.

To ensure our operational staff can cater for our patients’ individual needs, they are well trained in basic first aid, manual handling, infection prevention and control and driving as well as specialist bariatric training for many staff too. We ensure they have the right equipment to provide the highest quality service to our patients.

Our fleet 

Amongst our 350-strong fleet of PTS vehicles we have cars with wheelchair capacity, ambulance vehicles which can either provide multiple seating or be adapted to allow wheelchair access. The Trust also has a considerable number of ambulance vehicles with stretcher and bariatric capacity too. Our wheelchair-users may be able to travel in their chair, although where possible they will be transferred to a seat for the journey. Some journeys are completed by selected taxi companies or volunteer drivers.

What did we do?

It was agreed that the PTS service would be the service area where evidence would be gathered and subsequent EDS3 assessment would take place and grading undertaken for 2024/2025.  It has been acknowledged that the past few years have been challenging for all the NHS in responding to the COVID-19 pandemic and in that regard WMAS, like all ambulance services, has had a unique challenge due to the nature of the service, in dealing with the pandemic and responding to the ever-increasing demand and pressures as a result. 

Having gathered the evidence, an internal process assessment and grading took place, results of which are featured (below) in this report.

Analysis and grading

Call for evidence went out to the PTS team in respect of the current position of the service in respect of equality, inclusion and diversity in the business of the service.  Senior management of the PTS team were appraised of the EDS3 framework, and an analysis took place of the evidence that was provided.  The report and assessment were also made available to various network chairs and staff side for feedback and input.  The assessment team went through the evidence, and it was observed that there were areas which had equality embedded within the policy.

After assessing and analysing the evidence, the panel decided collectively that the service was at a developing stage as more work needed to be done to assure that the PTS service, that equality and inclusion considerations were embedded within the processes of the service. 

The evidence found that most elements of the service were at the development stage with one area classed as under-developed.  It was therefore decided, after much deliberation and discussion that the service would be overall graded as Developing.  It was also acknowledged that with an effective action plan and through further advice, support and guidance from the Diversity and Inclusion lead, the service could move from Developing to Achieving within the next 36 months, provided a manageable action plan was developed by the PTS team and worked on for delivery.

Trust Evidence Presented

Outcome

1A: Patients (Service users) have required levels of access to the service (simpler version of EDS2 2.1)

Evidence Supplied

Amongst our 350-strong fleet of PTS vehicles we have cars with wheelchair capacity, ambulance vehicles which can either provide multiple seating or be adapted to allow wheelchair access. The Trust also has a considerable number of ambulance vehicles with stretcher and bariatric capacity too. Our wheelchair-users may be able to travel in their chair, although where possible they will be transferred to a seat for the journey. Some journeys are completed by selected taxi companies or volunteer drivers.

Agreed Rating

Developing

Areas for improvement and recommendations

Areas for improvement: The internal assessment has also noted that there is further area for improvement in the following areas:

1a – The EDS outcome 1a is tentatively assessed as Developing at this stage due to the gaps in data collection especially the low percentage on ethnicity at 2% which may have an impact on service delivery.  It can be said confidently that those patients who require the PTS service and meet the criteria have access to the service.  As stated in the evidence representatives of the patient, where the patients themselves are unable to, will book the transport service on their behalf.  More work needs to be included in respect of patient data collection broken down by protected characteristics.  This outcome has been graded as Developing

Trust Evidence Presented

Outcome

1B: Individual Patients (service users) health needs are met. (simpler version of EDS2 1.2)

Evidence Supplied

Our PTS staff work operationally from 11 bases and four control rooms. Every patient journey we provide is booked and co-ordinated by our dedicated control room staff who are based in our Stafford, Coventry, Warrington and Frankley control rooms.

To ensure our operational staff can cater for our patients’ individual needs, they are well trained in basic first aid, manual handling, infection prevention and control and driving as well as specialist bariatric training for many staff too. We ensure they have the right equipment to provide the highest quality service to our patients.

Agreed Rating

Developing

Areas for improvement and recommendations:

1b – The evidence suggests that individual patients’ health needs are taken into account when delivering the service for the vast majority of the patient journey to hospital.  However more work needs to be done in respect of data collection for ethnicity characteristics.  Also further data needs to be gathered around the usage of interpreting and translations services for Disability and ethnicity.  This outcome has been graded as Developing.

Trust Evidence Presented

Outcome

1C: When patients (service users) use the service, they are free from harm (Like EDS2 1.4)

Agreed rating

Developing

Areas for improvement and recommendations:

1c – Developing at this stage based on the available evidence – Improvements would be around better data collection

Trust Evidence Presented

Outcome

1D: When patients (service users) report positive experiences of the service (Like EDS2 2.3)

Agreed rating

Developing

Areas for improvement and recommendations:

1d – Patient survey (NEPS) does show the most protected characteristics of the patient however the numbers are low in some areas such as ethnicity. The Small survey which looks at the Vehicle/Transport and appropriateness captures Age, Gender, Disability, Ethnicity and Disability so most of the Protected characteristics are covered here (UHCoventry & Warwickshire but this is a small sample from a particular area and going forward – this could be expanded).  The Friends and Family Test survey is based on a small sample and does not capture information for most Protected characteristics (Ethnicity 0%). Patient Experience Survey does not include information on some protected characteristics.  This outcome has been graded as Developing

What difference did we make?

The difference that this piece of work made was it enabled the Trust to identify potential gaps within the function of the Patient Transport Service.   The areas identified that need further work will be shared with the PTS team so service improvements can be made going forward

What were the keys to our success?

In order to get this project off the ground, collaborative working with the PTS team, (who approved the approach in the application of the EDS) was crucial where appropriate support and advice was given having had discussions with colleagues in determining which service to pick. Further, setting out the business case for the approach used in the application of the EDS3 framework and providing a sound rationale was also key to get the ‘buy in’ from the PTS team.  It was important to highlight the sound business case for review of the PTS service.  By analysing the PTS EDS 3 findings and sharing the findings with the PTS team it is envisaged that key gaps will be addressed which will lead to a service which is accessible to all.

Domain 2: Workforce Health and Wellbeing

Enabling our diverse workforce to be healthy, with a sense of well-being is crucial to high-quality patient care. Therefore, a fundamental part of WMAS’s ambitions is strengthening and building on the available health and well-being support.

Scoring Table

• Mohammed Ramzan – EDI Lead
• Louise Jones – Recruitment Manager
• Lucy Mackcracken – HR Lead
• Manjeet Malhi – Health and Wellbeing Manager
• John Eames – DCA Staff Network
• Tim Atherton – Military Network
• Suman Bhambra/Raul G – Student Network
• Keeling Hutton/M Azim/KB – ONE (BME) Network
• Ash Deakins – Proud Network
• Sonia Bhattle/Rebecca Parker-Williams – Women’s Network
• Lucy Butler – FTSU Guardian
• Jacquelin Murphy – Staffside
• Jason Kirkham – Staffside
• Reena Farrington – Staffside
• Agreed scores for all areas of the Domain
• 3A – 1
• 3B – 1
• 3C – 2
• 1
• Total Score for Domain 2
• 6

Trust Evidence Presented

Outcome

2A: When at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions.

Evidence Supplied

HWB Website – WMAS Wellbeing | Health and Wellbeing  – promoting physical health, mental wellbeing, slimming world, cycle to work, smoking & alcohol support

• HWB Champions,
• Diversity Champions
• Menopause Champions
• QWELL
• Health & Wellbeing Manager in post
• Mental Wellbeing Practitioner Service
• Health checks at roadshows -25 sites visited 2023 to promote health and wellbeing of staff 
• October 24 first virtual HWB day very successfully implemented offering a wide variety of drop in sessions for staff to attend
• NHS health checks available on sites
• Blood & Transplant awareness visits to various Trust sites as part of roadshows and long service awards
• Network events – South Asian Heritage awareness, disability awareness events, including cultural day
• TASC including Crisis Line
• SALS service, launch of SALS for Leaders. SALS Co-ordinator post secondment commenced November 24 for 12 month project
• Stress Policy support with new stress risk assessment tool implemented December 24
• Slimming World voucher scheme
• Cycle to Work scheme
• Health and Carer Passport Schemes
• Occupational Health
• HR and management support
• Listening Centre – counselling support
• Climbing out charity
• Trade Union support
• Statutory and Mandatory Training for all staff, covers HWB support
• Induction covers HWB support
• Cancer champions
• HWB conversation as part of PDCs
• Flexible working policy and training package for mangers.
• Roll out and implementation of The Decider Skills training
• HWB Newsletter

Agreed Rating

2

Owner for Domain

Mohammed Ramzan: EDI Lead. Supported by Lucy Mackracken, Manjeet Malhi and Barbara Kozlowska (People Directorate).

Feedback from evidence review sessions:

There have been several initiatives which have been championed over the past couple of years and especially in 2023/24 with the establishment of the Diversity Champions which has enhanced the support to staff in terms of their health and well-being.  The health and well-being team have visited 25 sites, reaching out to staff from different demographics and all backgrounds which has been a huge success.  It can be stated with a great degree of confidence that diverse staff from most protected characteristics have had access to health and well-being initiatives due to the close collaboration of the team with staff networks.

The Chaplaincy service has also been expanded to include chaplains from multi faiths which also feeds into the health and well-being offer to staff.

Whilst the guidance states that the organisation should monitor the health of staff from different protected characteristics, which is open to interpretation of how this is achieved, it can be reported that staff members who disclose health conditions to their line managers, that these are managed in an appropriate manner with flexible working an option where appropriate.   Generically, health checks have been undertaken as part of the health and well-being roadshows.

Trust evidence presented:

Outcome 2B: When at work staff are free from abuse, harassment, bullying and physical violence from any source.

Evidence supplied:

• Rebranded Resolutions Procedure (Grievance) with greater emphasis on resolving concerns at an early level
• Relaunch of Trust values and behaviours framework that all staff are expected to adhere to
• Dignity at work and Resolution Manager training package
• Diversity champions
• Trained mediators in place across the Trust
• Sexual safety and awareness workstream
• All areas of the Trust have an allocated HR Advisor and HR Manager to provide advice and support
• FTSU Guardians and Ambassadors
• Weekly briefing articles raising awareness of successful prosecutions of violence and aggression experienced
• Domestic Abuse and Sexual Assault | WMAS Wellbeing
• WMAS Wellbeing | Health and Wellbeing 
• Online Domestic Abuse Workshop by Samantha Billingham @sodahq.uk
• ER54 process
• Encouraging calling out of inappropriate behaviours observed
• Race, equality and inclusion charter launched as well as commitment to being an anti-racist organisation.
• Awareness and education package available and implemented to complement roll out of anti-racism charter
• Race, equality and inclusion standalone module developed by ICB embedded into statutory and mandatory workbook for all staff 24/25

Agreed Rating:

Developing 1

Owner for Domain:

Mohammed Ramzan: EDI Lead. Supported by Lucy Mackracken, Manjeet Malhi and (People Directorate).

Feedback from evidence review sessions:

This outcome is deemed at the Developing stage acknowledging that more needs to be done which is then reflected in the 2025 staff survey.  However, it was reported that the Trust has a robust reporting process called the ER54 where staff can report physical and verbal abuse, – where everyone is supported to report incidents and appropriate actions are taken. Data is collected for ethnicity, age and gender and looking forward there are discussions in place to collect Disability data too.  Staff are supported to report incidents to the police where this is an appropriate course of action.

There is also appropriate support for staff and staff are signposted to a dedicated page in the Health and Wellbeing Website and our external website

The WRES data along with staff survey suggests that there is still much to be done in regard to staff experiencing harassment and discrimination from fellow members of staff which reflected this outcome to be a Developing stage. 

It was therefore recommended that an action plan is developed to address some of the concerns identified at the assessment and grading event as follows:

• ER54s not always filled in so work and promotion around this
• Continued support for staff who are victims of abuse

Trust evidence presented:

Outcome 2C: Staff have access to independent support and advice when suffering from stress, abuse, bullying, harassment, and physical violence from any source.

Evidence Supplied:

• QWELL
• Mental Wellbeing Practitioner Service
• Listening centre – counselling support
• Suicide lite and MHFA courses for staff
• Mandatory Zero Suicide Alliance (ZSA) training
• Stress policy support including Stress Risk Assessment Tool
• HWB Website – WMAS Wellbeing | Health and Wellbeing  – promoting mental wellbeing support
• Climbing out charity
• Domestic Abuse and Sexual Assault | WMAS Wellbeing
• HR and management support
• SALS
• SALS for Leaders
• TASC including Crisis Line
• Trade Union support
• Occupational Health
• HWB Champions
• Diversity Champions
• Freedom to Speak Up Guardians are embedded in the organisation. Staff can report openly, in confidence or anonymously
• FTSU Ambassadors
• Relevant staff networks are active and accessible
• Student Support Officers

Agreed Rating

Achieving 2

Owner for Domain

Mohammed Ramzan: EDI Lead. Supported by Lucy Mackracken  (People Directorate).

Feedback from evidence review sessions:

Achieving 2

There are a number of support mechanisms for staff to tap into when support and advice is needed. 

Equality Impact Assessment process is in place and EIAs are completed on policy development and review and the expectation would be that when any amendments are made to harassment and bullying policy that the EIA process would be utilised to ascertain any impacts

WMAS has and supports Union representatives who are impartial.  FTSU guardians are embedded within the organisation with FTSU champions support across the organisation supported by 2 staff.  WMAS has 5 staff networks which are accessible and active for staff to seek support and are staff led.

Trust evidence presented:

Outcome 2D: Staff recommended the organisation as a place to work and receive treatment.

Evidence supplied

Staff Survey 2022/23 – 2760 responses

Pulse Survey 2022/23 – 590 responses

Staff Survey 2023/24 – 2661 responses

Pulse Survey 2023/24 – 943 response

I would recommend my organisation as a place to work:

2022/23

Staff Survey 41.8%

Pulse Survey 32.2%

2023/24

Staff Survey 44%

Pulse Survey 29.6%

I would NOT recommend my organisation as a place to work:

2022/23

Staff Survey 32.7%

Pulse Survey 43.5%

2023/24

Staff Survey 30.2%

Pulse Survey 45.9%

If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation:

2022/23

Staff Survey 51%

Pulse Survey 43.4%

2023/24

Staff Survey 55.4%

Pulse Survey 42.1%

If a friend or relative needed treatment I would NOT be happy with the standard of care provided by this organisation

2022/23

Staff Survey 22%

Pulse Survey 31.1%

2023/24

Staff Survey 18%

Pulse Survey 27.6%

Feedback from evidence review sessions:

In the Staff survey 44%% of the staff would recommend WMAS as a place to work and 30.2% Would NOT.  This is an improvement from last years staff survey .  In the Pulse survey these figures have declined from last years.

There has been continued improvement in the staff survey with 55.4% of staff would be happy with standard of care, however in the pulse survey this has declined from last year.  Currently there is no evidence that experiences from BAME, Disability and LGBT+ are compared with other staff.

It should be noted that a direct comparison to last year’s surveys cannot be made as the number of responses differ as well as the personal.  It is therefore recommended that these survey results should be seen as a snapshot, with a view of improving staff and patient experience through targeted work.

This outcome was therefore deemed to be at a Developing stage.

Domain 3: Inclusive Leadership

To truly create the conditions for high quality, compassionate and continually improving healthcare, leaders must understand and better nurture inclusiveness, promote equity and value diversity. The Board understand this and are committed to creating a culture of compassion whereby diversity is encouraged and celebrated, enabling an environment where all staff are empowered and have a positive experience.

Scoring Table

• Mohammed Ramzan – EDI Lead
• Louise Jones – Recruitment Manager
• Lucy Mackcracken – HR Lead
• Manjeet Malhi – Health and Wellbeing Manager
• John Eames – DCA Staff Network
• Tim Atherton – Military Network
• Suman Bhambra/Raul G – Student Network
• Keeling Hutton/M Azim/KB – ONE (BME) Network
• Ash Deakins – Proud Network
• Sonia Bhattle/Rebecca Parker-Williams – Women’s Network
• Lucy Butler – FTSU Guardian
• Jacquelin Murphy – Staffside
• Jason Kirkham – Staffside
• Reena Farrington – Staffside

Agreed scores for all areas of the Domain

• 3A – 1
• 3B – 1
• 3C – 2
• 1

Total Score for Domain 3

6

Trust Evidence Presented:

Outcome 3A: Board members, system leaders (Band 9 and VSM) and those with line management responsibilities routinely demonstrate their understanding of, and commitment to, equality and health inequalities.

Evidence Supplied

Both equality and health inequalities are standing agenda items and discussed in board and committee meetings.

Board members and senior leaders meet staff networks at least 3 or more times a year.  Staff networks have a senior sponsor.

Board members hold services to account, allocate resources, and raise issues relating to equality and health inequalities on a regular basis.

Board members and senior leaders engage in religious, cultural or local events and/or celebrations.

Chief Executive has made a pledge and commitment, as part of the Black Country ICS work that is ongoing to advance and improve equalities in the system. 

Agreed Rating

2

Owner for Domain

Mohammed Ramzan, EDI Lead. Supported by Carla Beechey (People Directorate).

Feedback from evidence review sessions:

Equality, diversity, inclusion, and Health Inequalities form part of the cover sheet which is attached to reports and reminds Board members of the duties under the Equality Act 2010 and consider those where relevant. 

Board members, and senior leaders have attended events such as the women’s network event, South Asian Heritage Month celebration, culture event and Chaplaincy event in Birmingham all in 2024/25.  All promotions and attendance have featured in the weekly brief which goes out to all staff.

In addition, Board members & senior leaders have signed up to the inclusion pledge.  WRES, WDES, GPG, and associate action plans are monitored through appropriate governance mechanisms (DISAG steering group, The People Committee) which are chaired by Board or senior management.

More work needs to be done in respect of line manager commitment to equality, diversity, and which needs to be reflected in the action plan.

Each Staff Network has an Executive sponsor, although it needs to be clear what support they provide.

There is mandatory equality training for all staff, including senior leaders.

Trust Evidence Presented

Outcome 3B: Board/Committee papers (including minutes) identify equality-related impacts and risks and how they will be mitigated and managed.

Evidence Supplied

Both equality and health inequalities are discussed in most board and committee meetings. Actions associated with equality and health inequalities are recorded and reported on.

Equality and health inequalities impact assessments are completed for some projects and policies and are signed off at senior level. BME staff risk assessments are completed.

Agreed Rating

Achieving 2

Owner for Domain

Carla Beechey (Director of People)

Feedback from evidence review sessions:

Achieving 2

Equality impact Assessments (EIA) template are embedded into the policies for when they are developed or reviewed.  

EIA process is completed for projects and the ones completed are featured in the Equality annual report. All reviewed policy documents did have a full equality impact assessment, although discussion of health inequalities in these assessments was still limited. There was some evidence of actions being identified to mitigate and manage risks.

Workforce Race and Disability Equality Standards (WRES/WDES) and the Gender Pay Gap, and other data have been used to develop action plans with monitoring via the Diversity and Inclusion Steering Group (DISAG). The annual Public Sector Equality Duty (PSED) report will include information on how we as a Trust are meeting our duties under the Equality Act 2010.

A dedicated Equality Steering group (DISAG) is monitoring progress on all the Equality action plans and the EDS 2023-25 action plan will form part of the progress reports tabled at these meeting on a quarterly basis and an update shared with the People’s Committee.

Trust evidence presented:

Outcome 3C: Board members, system and senior leaders (Band 9 and VSM) ensure levers are in place to manage performance and monitor progress with staff and patients

Evidence Supplied

Board members, system and senior leaders ensure the implementation and monitoring of the relevant below tools. Interventions for unmet goals and objectives are present for the relevant below tools.

Organisations are able to show year on year improvement using Gender Pay Gap reporting, WRES and WDES. Board members, system and senior leaders monitor the implementation and impact of actions required and raised by the below tools:

WRES (including Model Employer), WDES, Impact Assessments, Gender Pay Gap reporting, Accessible Information Standard, end of employment exit interviews, PCREF (Mental Health), EDS 2022.  Chief pledge to the Black Country ICS and System level action plan reporting on Equality and Inclusion.

Agreed Rating

Excelling 3

Owner for Domain

Carla Beechey (Director of People)

Feedback from evidence review sessions:

WRES, WDES, and GPG data is collected, action plans developed. implemented and submitted to commissioners within the timeframe set. 

Equality Impact Assessment process developed and utilised in policy development.  The EIA template is also on the intranet for staff to use and the EDI lead provides additional support and guidance and training.

Overall Scores and Rating for Organisation

• Domain 1 Score – 4
• Domain 2 Score – 6
• Domain 3 Score – 6
• Total score for 3 Domains: 16
• Rating
• Domain 1 – Developing
• Domain 2 – Achieving
• Domain 3 – Achieving

Conclusion

For 2024/25 the Patient Transport Service has been assessed this year for Domain 1.  It should be noted however that a new service is often chosen every year for Domain 1 and the assessment and grading is applied based on evidence gathered.  This means that a service for example like Procurement, which was assessed last year, was graded as Achieving after a remedial action plan was put in place.  A new service, after having applied the assessment and grading scores will invariably differ to the previous year which gives an overall score which is less than last year, – although improvements have been made in other outcomes as has been the case this year.  For this reason, it is felt that an overall score may not be reflective of the progress and achievements made and that each domain should be judged separately for the progress that it has made – and which will show a true reflection of where the organisation is in terms of improvements in equality. 

There are several areas which have been assessed as Achieving with others as Developing in Domain 2.  There has been a marked improvement in Domain 3, Outcome 3b which has moved from Developing to Achieving from last year.  This is largely due to 57 members of staff being trained on Equality Impact Assessment framework and the process being embedded in Policy stat and at key governance routes before a [project or policy is approved.  Further improvement in 3d which has moved from Achieving to Excelling and this is due to the pledge that the Chief has made as part of the Black Country Integrated Care System on equality improvement on data gathering for Gender Pay Gap, Ethnicity Pay Gap and Disability Pay Gap. 

The EDS assessment and action plan will be presented to the Diversity, and Inclusion Steering Group (DISAG) for monitoring going forward and also shared at the quarterly Peoples Committee for assurance.

Appendix 1: EDS Outcomes

Domain 1: Commissioned or provided services

Outcome
1A: Patients (service users) have required levels of access to the service
1B: Individual patients (service user’s) health needs are met
1C: When patients (service users) use the service, they are free from harm
1D: Patients (service users) report positive experiences of the service

Domain 2: Workforce health and well-being

Outcome
2A: When at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions
2B: When at work, staff are free from abuse, harassment, bullying and physical violence from any source
2C: Staff have access to independent support and advice when suffering from stress, abuse, bullying, harassment and physical violence from any source
2D: Staff recommend the organisation as a place to work and receive treatment

Domain 3: Inclusive leadership

Outcome
3A: Board members, system leaders (Band 9 and VSM) and those with line management responsibilities routinely demonstrate their understanding of, and commitment to, equality and health inequalities

3B: Board/Committee papers (including minutes) identify equality and health inequalities related impacts and risks and how they will be mitigated and managed

3C: Board members, system and senior leaders (Band 9 and VSM) ensure levers are in place to manage performance and monitor progress with staff and patients