The Diversity Practice 2010 - NHS Leadership Academy
The Diversity Practice 2010 - NHS Leadership Academy
The Diversity Practice 2010 - NHS Leadership Academy
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Embedding Equality, <strong>Diversity</strong> & Inclusion<br />
into <strong>NHS</strong> Governance<br />
Final Report<br />
November <strong>2010</strong>
Integr8 <strong>NHS</strong> - Final Report<br />
Embedding Equality, <strong>Diversity</strong> & Inclusion into <strong>NHS</strong><br />
Governance<br />
1. Introduction 3<br />
2. Background 5<br />
a. Scope of Intervention 5<br />
b. <strong>The</strong> Pilot Trusts 7<br />
3. Integr8 <strong>NHS</strong> methodology and approach 9<br />
4. National Outcomes 12<br />
5. Local Outcomes 14<br />
6. Key learning 22<br />
7. Conclusions and recommendations for the future 24<br />
Page 2
1. Introduction<br />
In January <strong>2010</strong>, the <strong>Diversity</strong> <strong>Practice</strong> was commissioned by the <strong>NHS</strong> Institute for Innovation and<br />
Improvement to support a pilot programme to build <strong>Diversity</strong> and Inclusion into the Business of <strong>NHS</strong><br />
Boards.<br />
<strong>The</strong> aim of the programme is to co-produce an accelerated development process which will support<br />
Boards to focus on inclusion in a way that engages them in the reality of the challenges they face as<br />
commissioners, providers and employers in the communities they serve. More specifically, the goal<br />
is to support Boards in developing the critical connections between equality, diversity and inclusion<br />
(EDI) and their core business; and identify what they need to do differently to ensure their “business<br />
delivers effectively to all its customers”.<br />
<strong>The</strong> issue of mainstreaming and embedding EDI continues to be an important aspiration for many<br />
public and private sector organisations. To support <strong>NHS</strong> Boards in achieving this aspiration the<br />
<strong>Diversity</strong> <strong>Practice</strong> has developed Integr8 <strong>NHS</strong> – a cutting edge approach that practically aligns and<br />
effectively integrates <strong>NHS</strong> governance, leadership and overarching business models with EDI.<br />
This report outlines the process, learning and outcomes from the application of Integr8 <strong>NHS</strong> to 3<br />
<strong>NHS</strong> Trusts: <strong>The</strong> North West Ambulance Service, Kings College Hospital <strong>NHS</strong> Foundation Trust, and<br />
the <strong>NHS</strong> North West Strategic Health Authority. <strong>The</strong> report is laid out as follows:<br />
1. Firstly, it outlines the background to the project with regards the scope of work required and<br />
the local context of the three Trusts.<br />
2. <strong>The</strong> next section provides an overview of the Integr8 <strong>NHS</strong> methodology. A fuller and more<br />
detailed outline of the approach is provided in the Integr8 <strong>NHS</strong> Toolkit report.<br />
3. We then assess the outcomes from the intervention across all the Trusts and for each one. In<br />
summary, the key point to note is that the intervention has had a significant impact on<br />
issues of governance and leadership of EDI, and either moved the individual Trust further<br />
along on its journey to being an exemplar High Performing Inclusive Organisation, or acted<br />
as a catalyst for the legacy sharing of good EDI practices with other Trusts.<br />
4. We then provide a summary of the key learning from the intervention with regards<br />
governance of EDI across the Trusts and the approach to Board development in this area.<br />
5. Finally, we outline our conclusions and recommendations. Critically, these include<br />
a. A one-off intervention can address some of the EDI issues that the Board may face,<br />
but for sustainable impact further support by way of coaching at Board level and<br />
possibly at sub- committee level as well as external accountability is needed.<br />
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. <strong>The</strong> timeframe for a project of this nature to fully deliver on its objectives should be<br />
12 to 18 months minimum. This would give sufficient time for measurable outcomes<br />
to become evident.<br />
c. <strong>The</strong> facilitation of an intervention like this requires expertise in EDI, change<br />
management, and strategic thinking, as well as experience and well-developed skills<br />
in group facilitation at Board level.<br />
Page 4
2.1. <strong>The</strong> Scope of the Intervention<br />
2. Background<br />
At the outset the scope of works was very wide. <strong>The</strong> <strong>Diversity</strong> <strong>Practice</strong> was asked:<br />
1. To design and deliver 3 pilot Board D&I Development interventions (co-produced with the<br />
Boards involved), which will focus upon:<br />
<br />
<br />
<br />
using inclusion as strategic lever for improving access and quality in health care and<br />
reducing inequalities in health;<br />
releasing untapped innovation and productivity within the workforce;<br />
generating connection with the populations we serve, and improving prevention.<br />
2. To work with 3 different, interested and willing Boards who are eager to address and are<br />
grappling with the challenges of delivering inclusive health and health care services whilst<br />
being an inclusive employer and providing inclusive leadership. To work with these Boards to<br />
actively address, explore and generate action on a number of key questions including:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
How can Boards define and position inclusion as a strategic opportunity?<br />
What’s the compelling case for inclusion and diversity?<br />
How can Boards use the Constitution as an opportunity to ensure comprehensive<br />
services to all and that everyone counts?<br />
How does inclusion deliver improved access and quality in health and health care, and<br />
reduce inequalities in health?<br />
How does inclusion in employment and leadership release innovation and productivity?<br />
How does inclusion improve our engagement and involvement with our populations and<br />
aid prevention?<br />
What measures can Boards use to understand the impact of inclusion and diversity?<br />
How can Boards embed inclusion and diversity into everything they do without losing<br />
sight of it?<br />
3. To engage the Boards in discovery and learning and taking action on how they behave<br />
differently, what they do differently in their business and in their business context to ensure<br />
and assure that their organisations are for example:<br />
- commissioning for inclusion<br />
- delivering inclusive health and health care services<br />
- engaging patients, carers, the general public, local populations inclusively<br />
- leading inclusively<br />
- recruiting for inclusion and diversity<br />
- managing for inclusion and diversity<br />
- harnessing innovation from inclusion and diversity<br />
- harnessing productivity and quality improvement from inclusion and diversity<br />
- improving prevention through inclusion<br />
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- accounting for inclusion<br />
<strong>The</strong> above list provides examples of the individual issues that could have been addressed, subject to<br />
the particular context for each Board, with there being no requirement that all these issues are<br />
tackled.<br />
4. Within the budget and time constraints to:<br />
<br />
<br />
<br />
<br />
Undertake research and gather the appropriate information to present an overview of<br />
the Board’s current D&I position, approach and status, and the business case for<br />
building D&I into the Board’s business and positioning it at the strategic heart of the<br />
organisation<br />
Engage Board members individually and collectively so as to increase their<br />
o knowledge and understanding of D&I, its application at a strategic governance<br />
level, and its relationship to key <strong>NHS</strong> drivers such as QIPP;<br />
o individual and collective D&I leadership competence and capability;<br />
o governance and oversight of D&I as a strategic lever for improving access and<br />
quality in health care, reducing inequalities in health and attracting and<br />
retaining a talented, motivated and engaged workforce;<br />
o and to provide Board level support for the implementation of the action plans<br />
falling out from the intervention<br />
Develop a model of working, materials, interventions, outcomes from the process which<br />
have the potential to be replicable with other Boards and amenable to inclusion in the<br />
electronic Board Development Platform and adaptable to form part of a wider Quality<br />
Innovation Productivity and Prevention Board development offer<br />
Undertake an evaluation of the Board D&I development intervention, and produce a<br />
brief report highlighting learning from the process and illustrating impact as reported by<br />
the Boards involved<br />
However, as the project evolved, we became more focused on achieving outcomes in the<br />
following areas:<br />
1. Organisational shift – <strong>The</strong> Board achieves its aspirations and success measures for the<br />
project.<br />
2. Embedding D&I – <strong>The</strong> Board has a better understanding and a shared point of view of the<br />
critical business relationship between D&I, quality healthcare for all, its strategic priorities<br />
and plan, and national <strong>NHS</strong> strategic drivers such as World Class Commissioning, and<br />
Quality, Innovation, Productivity and Prevention.<br />
3. Inclusive <strong>Leadership</strong> – Increased Board member competence and confidence in their<br />
individual and collective ability to take the lead on mainstreaming and embedding D&I in the<br />
organisation, the management of staff, and the delivery of services.<br />
4. Improved Governance – <strong>The</strong> Board increases its effective governance and oversight of D&I.<br />
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5. Organisational benefits – <strong>The</strong> creation and implementation of a clear action plan and initial<br />
improvements in the diversity of the workforce, the development of an inclusive workplace,<br />
and equality in service provision to patients and the public.<br />
2.2. <strong>The</strong> Pilot Trusts<br />
<strong>The</strong> three Boards we worked with were:<br />
<strong>The</strong> North West Ambulance Service Trust (NWAS)<br />
NWAS is the busiest and one of the most diverse ambulance services in the country, providing<br />
services to seven million people in an area of 5,400 square miles. It employs around 5,400 staff,<br />
working out of multiple locations spread throughout the region. It provides services for patients in a<br />
combination of rural and urban communities, in coastal resorts, in affluent areas and in challenging<br />
inner city areas; as well as providing services for a large transient population of tourists, students<br />
and commuters.<br />
<strong>The</strong> diverse geographical and demographic spread of the region it serves means that issues of<br />
diversity and inclusion are fundamental to the successful achievement of its strategic aims and<br />
objectives, while at the same time being challenging to effectively implement. Nevertheless, NWAS<br />
is “committed to developing a culture and practices which value difference both in employment and<br />
in the delivery of individualised and responsive patient care and to working with patients, carers and<br />
communities to achieve this” (EDI Vision statement).<br />
King’s College Hospital <strong>NHS</strong> Foundation Trust (KCH)<br />
KCH is one of London’s largest and busiest teaching hospitals, serving a patient population of<br />
700,000 and with a deserved reputation for providing excellent local healthcare to the London<br />
Boroughs of Lambeth and Southwark, and a range of specialist services for patients across South<br />
East England and beyond.<br />
KCH is recognised nationally and internationally for work in liver disease and transplantation,<br />
neurosciences, cardiac services, blood cancers and foetal medicine, and the Trust plays a key role in<br />
the training and education of medical, nursing and dental students.<br />
KCH works closely with other healthcare organisations, such as local Primary Care Trusts and also has<br />
strong academic links with the King’s College London School of Medicine and Dental Institute, and<br />
the Institute of Psychiatry. In addition KCH is part of King’s Health Partners Academic Health Sciences<br />
Centre (AHSC), a pioneering collaboration between King’s College London, and Guy’s and St<br />
Thomas’, King’s College Hospital and South London and Maudsley <strong>NHS</strong> Foundation Trusts. This<br />
collaborative working is an ongoing strategic priority for KCH.<br />
KCH is recognised as one of the leading <strong>NHS</strong> Trusts with regards Equality, <strong>Diversity</strong> and Inclusion<br />
(EDI). It has moved a long way in recent years, significantly improving and embedding good EDI<br />
practices, and in many areas being ahead of comparator Trusts.<br />
Page 7
<strong>The</strong> <strong>NHS</strong> North West Strategic Health Authority (<strong>NHS</strong> NW)<br />
<strong>NHS</strong> NW is one of the largest SHA in the country and the <strong>NHS</strong> is the largest employer, commissioner,<br />
procurer and service provider in the region. Comprising 64 <strong>NHS</strong> organisations and employing<br />
222,000 people it covers the biggest geographical area of any SHA in the country. <strong>The</strong> SHA oversees<br />
the provision of services for approximately seven million people living in a combination of rural<br />
and urban communities, in coastal resorts, in affluent areas and in challenging inner city areas;<br />
as well as for a large transient population of tourists, students and commuters.<br />
<strong>The</strong> SHA recognises that issues of diversity and inclusion are integral to creating a world class health<br />
service that delivers better health and workforce outcomes for all people. <strong>The</strong> diverse geographical<br />
and demographic spread of the region it serves and the complex needs of its patient population<br />
means that this will be a challenge to achieve, but it has made a significant commitment to and<br />
investment in equality and diversity, so that equality underpins our transformation into a quality<br />
health care system (Business Plan 09/10)<br />
Included in the E&D vision is for <strong>NHS</strong> North West to be acknowledged and recognised as a leader of<br />
equality and diversity in the workplace and more importantly in the commissioning and delivery of<br />
high-quality health care services for all.<br />
Page 8
3. Integr8 <strong>NHS</strong> Methodology and Approach<br />
<strong>The</strong> issue of mainstreaming and embedding EDI continues to be an important aspiration for many<br />
public and private sector organisations. To support <strong>NHS</strong> Boards in achieving this aspiration the<br />
<strong>Diversity</strong> <strong>Practice</strong> has developed Integr8 <strong>NHS</strong> – a cutting edge approach that practically aligns and<br />
effectively integrates <strong>NHS</strong> governance, leadership and overarching business models with EDI.<br />
Integr8 <strong>NHS</strong> builds on the National Standards, Local Action Planning Framework, World Class<br />
Commissioning, Integrated Governance and CQC Standards as the core foundation for embedding<br />
and mainstreaming EDI into <strong>NHS</strong> governance policy and practice.<br />
Working within the Cadbury, Turnbull and Higgs standards for corporate governance, risk control<br />
and role and responsibilities of boards, Integr8 <strong>NHS</strong> seeks to increase each Board’s ability to more<br />
effectively monitor, scrutinise and constructively challenge from the perspective of EDI the strategic<br />
levers and drivers for quality, innovation and improvement, and to deliver inclusive health and<br />
health care services whilst being an inclusive employer and providing inclusive leadership.<br />
<strong>The</strong> overall approach is built on the principles of:<br />
<br />
<br />
collaborative partnership – to create robust processes that take account of individual<br />
Board contexts, and ensure interactions with each Board maximise engagement and<br />
time with the need for flexibility;<br />
appreciative enquiry – to build on the good practices already in place; inclusive action<br />
that seeks out and incorporates the perspectives of the diverse staff, patients and<br />
community representatives;<br />
Page 9
a“whole system” perspective – in order to create change strategies and implementation<br />
plans that take account of the complex adaptive nature of the <strong>NHS</strong>. Above all, the<br />
approach seeks to ensure that there is an alignment between the key <strong>NHS</strong> strategic<br />
drivers, governance & leadership, and diversity & inclusion.<br />
<strong>The</strong> Integr8 <strong>NHS</strong> methodology is an 8 step process for embedding equality, diversity and inclusion<br />
into <strong>NHS</strong> governance. 1<br />
Foundation<br />
<strong>The</strong> initial steps in the process are focused on project set up, engagement and ownership with the<br />
Board; analysis of current situation and aspirations; and individual inclusive leadership support to<br />
each board member.<br />
i. Board Engagement – Initial consultation with Chief Executive/Chair, followed by<br />
engagement with the full Board to introduce and take ownership of the Integr8 <strong>NHS</strong><br />
development process.<br />
ii. EDSnap Audit - an Equality, <strong>Diversity</strong> and Inclusion Snapshot audit to determine the current<br />
positioning, integration and impact of D&I on the Board and the organisation, comprising of<br />
documentary review, short interviews with a few Board members, and an online survey of a<br />
small sample of key staff, patient and community representatives. <strong>The</strong> output from this step<br />
is a 40 page EDSnap audit report, outlining where the Trust is on its EDI journey from<br />
“compliance” to “delivering outcomes” to “being an exemplar high performing inclusive<br />
organisation”, and indicating areas where the Trust or the Board could benefit from further<br />
development or intervention.<br />
iii. Strategic inclusive leadership review – each Board member receives a personal, confidential<br />
session with an executive leadership coach, to support and develop their inclusive leadership<br />
commitment and understanding. A unique aspect of the review is the use of the Factor 8<br />
Different Leaders Assessment Tool. This is an innovative, cutting edge 360 online tool which<br />
provides an assessment of the leadership competences critical for leading a diverse<br />
workplace serving diverse patients and clients. Through the individual 34 page report they<br />
receive and the executive coaching, each Board member has the opportunity to develop a<br />
personal action plan to grow their competence and confidence as inclusive leaders.<br />
Board Development Workshop<br />
Using the output from the foundation steps, a Board Development Workshop is then held. <strong>The</strong> next<br />
3 steps in the Integr8 <strong>NHS</strong> process are applied during the workshop. An example of the output from<br />
the NWAS Board Development Workshop is provided as Appendix 1.<br />
1 A fuller outline of the Integr8 <strong>NHS</strong> is provided in the Toolkit Report<br />
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iv. E-QIPP – the first part of a facilitated Board workshop, develops the vision for EDI, the<br />
business case for building D&I into the Board’s business, and examines the critical<br />
connection between D&I and achieving QIPP.<br />
v. I-Lead – the second part of the workshop examines what it means to lead effectively on D&I<br />
and develops a common framework of inclusive leadership competences, behaviours and<br />
values for Board members.<br />
vi. We Govern – the final session the workshop, builds effective mechanisms for Board<br />
leadership and oversight of D&I, for example through identifying and developing a Board<br />
level <strong>Diversity</strong> Scorecard to track progress against pre-determined success measures.<br />
Taking Action<br />
<strong>The</strong> final steps involve drawing up and implementing actions from the Board development workshop<br />
and reviewing the Integr8 <strong>NHS</strong> process.<br />
vii. We Implement – all the agreed actions are consolidated into an implementation plan, and<br />
<strong>Diversity</strong> <strong>Practice</strong> consultants attended meetings with the Trust to coach and support the<br />
Board in executing the plan. An example of the NWAS Dashboard Report that was put to the<br />
Board for approval is provided as Appendix 2.<br />
viii. Evaluation & Review – as this was a pilot, there was a requirement for ongoing evaluation,<br />
sharing of learning and good practices at each step of the process, as well as an overall final<br />
review, evaluation and refinement of the Board D&I Development Toolkit.<br />
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4. National Outcomes<br />
<strong>The</strong> Board D&I development intervention, through the Integr8 <strong>NHS</strong> process, has had a significant<br />
impact on the Trusts and moved all of them further along on their journey to becoming exemplar<br />
high performing inclusive organisations. To quote NWAS, “<strong>The</strong> development intervention has been<br />
very powerful in enabling the Board to critically evaluate its leadership and behaviours and has<br />
facilitated a prioritisation of key changes which are required to achieve a step change in delivery.”<br />
In looking across the Trusts there are a number of national outcomes that can be drawn. <strong>The</strong><br />
intervention has resulted in:<br />
1. Vision and Change: <strong>The</strong> refinement or clarification of the respective visions for EDI, a shared<br />
understanding of the vision across the Board, and a greater momentum for further change<br />
and focused attention to EDI.<br />
2. Governance & Planning: <strong>The</strong> development of new approaches to integrate and embed EDI<br />
into strategic governance and business planning, with more explicit links to strategic <strong>NHS</strong><br />
priorities.<br />
3. D&I Committee: <strong>The</strong> role of the Board Equality and <strong>Diversity</strong> Committee/Steering Group has<br />
been re-examined, strengthened and clarified, with the intent of making it a better agent of<br />
change, monitor of EDI performance, and vehicle for prioritisation of issues.<br />
4. Equality Impact Assessment: A more critical evaluation of equality impact assessments, to<br />
shift them from being just another process to being a more effective mechanism for the<br />
Board to use to mainstream and embed creative thinking and analysis of EDI.<br />
5. Inclusive <strong>Leadership</strong>: <strong>The</strong> reinforcement and enhancement of EDI knowledge and good<br />
behaviours among Board members, by creating a shared frame of reference around strategic<br />
inclusive leadership, resulting in greater confidence around EDI.<br />
6. Collective EDI <strong>Leadership</strong>: <strong>The</strong>re has been progress in terms of the prioritisation of EDI<br />
issues, and greater understanding and application of collective Board leadership of EDI has<br />
been developed.<br />
7. Outcomes Driven Focus: A greater emphasis has been placed on an outcomes based<br />
approach to EDI, not just a focus on processes.<br />
8. Workplace changes: <strong>The</strong> Boards have set in train a greater degree of engagement with<br />
managers and the workforce on EDI, for example through renewed or refocused Staff<br />
Engagement/<strong>Diversity</strong> Groups, diversity training programmes for Managers, and/or more<br />
extensive yet tailored communication with staff.<br />
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9. External Groups: Increased discussion, communication, involvement and accountability to<br />
local communities and diverse groups regarding service provision and development.<br />
10. Individual Learning: <strong>The</strong> development of personal actions by Board members to further<br />
enhance their confidence and competence as inclusive leaders.<br />
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5. Local Outcomes<br />
5.1. Results of the EDSnap Audit<br />
5.1.1. Areas of Good <strong>Practice</strong><br />
All three of the Trusts had moved a long way in recent years with regards D&I, significantly<br />
improving and embedding good EDI practices, and in many areas being ahead of comparator<br />
organisations. What is particularly noteworthy is that three Boards are firmly committed to EDI and<br />
actively promoting and taking on the EDI agenda. <strong>The</strong>re is an expressed desire for continuous<br />
improvement in this area – to be an exemplar EDI organisation. Among the areas of good practice<br />
we noted are:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
A values-driven leadership approach that views equality, diversity and inclusion as<br />
integral to organisational culture and behaviour, and to the successful attainment and<br />
delivery of high quality health care services for all; and therefore, not a separate boltedon<br />
activity operating in an ineffectual silo manner.<br />
<strong>The</strong> development of an open and inclusive culture in many parts of the organisations<br />
<strong>The</strong> growing engagement with diverse communities to address issues of access to<br />
services, employment opportunities, and patient experiences<br />
Initiatives to tailor patient care and service delivery to meet the needs of diverse groups<br />
and address health inequalities<br />
<strong>The</strong> growing representation of women managers at higher levels of the organisations<br />
<strong>The</strong> development and use of an EDI infrastructure of strategy, policies, <strong>Diversity</strong><br />
Steering Group/Committee, and structures for senior management accountability<br />
<strong>The</strong> widespread use of equality impact assessments<br />
<strong>The</strong> communication to staff of EDI issues and messages<br />
<strong>The</strong> explicit setting of targets by NWAS to address the under-representation of diverse<br />
groups in the workplace<br />
<strong>The</strong> work being done by KCH around “Living Kings Values” by KCH, the embedding of<br />
EDI within this, and the expectation and ambition to use this to bring about both a<br />
change in behaviours and in the organisational culture of KCH.<br />
<strong>The</strong> extensive and innovative diversity monitoring of patients at KCH<br />
<strong>The</strong> <strong>NHS</strong> NW has a clear, well articulated and outcome focused strategic plan for EDI<br />
that has been derived from careful and detailed analysis of its local context, and includes<br />
objectives, performance measures and actions to be taken, and is outcomes focused i.e.<br />
results and impact as opposed to activity and process.<br />
<strong>The</strong> <strong>NHS</strong> NW Equality Performance Improvement Toolkit is an excellent example of an<br />
SHA leading the way in terms of establishing standards of good practice and working<br />
collaboratively with <strong>NHS</strong> organisations to raise E&D standards.<br />
Examples of recent achievements from one or more of the 3 Trusts include:<br />
<br />
<strong>The</strong> provision of mandatory equality and diversity awareness training, with specific sessions<br />
on disability issues, for all staff<br />
Page 14
<strong>The</strong> inclusion of equality and diversity requirements within all personal development plans<br />
Through the Electronic Staff Record, the production of monthly staff profiling according to<br />
equality target grouping<br />
<strong>The</strong> production of an Equality Impact Assessment Toolkit for the assessment of all policies<br />
Systems have been put in place to ensure that E&D is mainstreamed throughout business<br />
plans, the assurance framework and master control plan.<br />
A system has been set up to ensure that all policies undergo EIA before being submitted for<br />
Board approval.<br />
Staff induction programme has been reviewed and induction pack includes E&D issues<br />
A Deaf Access training programme for nurses has been re-commissioned and other disability<br />
awareness programmes are ongoing.<br />
Participation in DoH national Pacesetters Programme; the Programme tackles health and<br />
workplace inequalities.<br />
Staff access to 24/7 independently run Harassment & Bullying Helpline<br />
Work experience programme and placements for people with disabilities<br />
Establishment of staff led diversity networks – Cultural <strong>Diversity</strong> Group, Deaf & Disability<br />
Workforce Group and Lesbian, Gay, Bisexual & Transgender Forum.<br />
Delivery of a range of recruitment initiatives including pre-recruitment training, community<br />
based training events, and targeted positive action initiatives.<br />
Recruitment of workforce to reflect its diverse community – 46% from BME backgrounds<br />
and proportion of middle/senior managers from BME increased from 25% in 2002 to 44% in<br />
2009.<br />
5.1.2. Areas for further Development<br />
1. EDI Vision, Strategy and Business Case:<br />
Clarity of purpose and direction of travel, along with a shared ownership of its strategic rationale<br />
are critical factors in successfully embedding good EDI practices and behaviours into any<br />
organisation and achieving the desired performance improvement. To some extent all the<br />
Boards would benefit from:<br />
a) A restatement and collective acknowledgement of the EDI vision and priorities, and an<br />
explicit linkage being made to organisational and <strong>NHS</strong> strategic objectives.<br />
b) Strategies that will deliver more stretch, challenge and the step change required to<br />
improve access to services, reduce health inequalities and increase the diversity of the<br />
workplace.<br />
c) Further communication of the strategic and business imperative, rationale and<br />
benefits of EDI to the staff. This communication needs to take place through channels<br />
and language that the staff will actively engage with and take on board.<br />
2. Board Monitoring and Scrutiny of EDI:<br />
<strong>The</strong> embedding and mainstreaming of EDI does not eliminate the need for specific focused<br />
governance anymore than this is the case for other strategic priorities such as finance or safety.<br />
Page 15
While the use of a specialist equality and diversity NED and the intent to equality impact assess<br />
all policies and Board papers are to be commended, further robust and more frequent scrutiny<br />
of EDI as part of the full Board agenda should be implemented, in line with other relevant<br />
strategic priorities. <strong>The</strong>re can be an over-reliance on a single Board specialist and a risk that EIAs<br />
become “just another process” rather than a tool for effective scrutiny and action. Generally, the<br />
Boards could benefit from:<br />
a) Consideration being given to further strengthening the collective engagement and<br />
leadership by all members of the Board, and to the breadth and depth of Board<br />
involvement in the <strong>Diversity</strong> Steering Group/Committees and their terms of reference.<br />
b) EDI being a standing item on the Board’s agenda supported by adequate time for<br />
discussion, debate and decisive action.<br />
c) Effective, outcomes-driven challenge of the EDI agenda being encouraged and<br />
undertaken by more than just a few Board members. <strong>The</strong> collective leadership ability to<br />
make the connection between EDI and the core business functions of the Trust is<br />
imperative.<br />
3. EDI Scorecard:<br />
Another area for further refinement is for Boards to centrally capture the totality of their<br />
strategic approach to EDI, the objectives and measurable results and outcomes, in a way that<br />
allows them to regularly track and monitor. What is required is an effective overarching<br />
monitoring framework that allows for both local ownership and action in addition to central<br />
oversight and scrutiny, and that can be used as a means to drive and sustain the required<br />
changes in behaviours.<br />
4. Patients, Communities and Service Delivery<br />
Whilst all the Boards had strategies and initiatives to engage with their patient populations,<br />
communities and tailor service delivery, there is nevertheless more that can be done and<br />
suggested areas for further development include:<br />
a) More regular and visible prioritisation by the Board of the effectiveness of service<br />
delivery to diverse patient groups, the outcomes from tackling health inequalities, and<br />
the success of tailored care.<br />
b) A greater use and leverage of the diversity within the workforce and community<br />
volunteers to support a better understanding of patient needs and the communities<br />
they come from, and to ultimately help improve the quality of patient care and health<br />
outcomes.<br />
c) Establishing an overall mechanism for centrally capturing the outcomes from initiatives<br />
to address health inequalities and the tailoring of service delivery, to better improve<br />
leadership and governance in this area and the communication with staff and<br />
stakeholders.<br />
d) More effective collection and use of patient monitoring and satisfaction data, to<br />
provide a better understanding of how diverse groups access services, what their patient<br />
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experience is, where health inequalities exist and to determine what the tailored<br />
healthcare requirements of diverse groups are.<br />
e) Undertaking further research, for example to better understand, evidence and address<br />
the implications of culture, spiritual belief, or sexual orientation on health care needs<br />
and provision.<br />
5. Workforce Representation<br />
Two of the Trusts are finding it challenging to increase the representation of people from a BME<br />
background and those with a disability, and of women in senior management. Whilst steps have<br />
been taken to address this and some progress has been made there is still more to be done. <strong>The</strong><br />
Boards could consider:<br />
a) Setting specific objectives for Executive Directors that are then held accountable for<br />
their achievement of diverse staff profiles.<br />
b) Introducing diverse recruitment panels – formally identifying and recruiting individuals<br />
from diverse groups to participate in the selection process as a way of bringing a<br />
different viewpoint to recruitment and appointment decisions.<br />
c) Implementing diversity recruitment training, with a specific focus on unconscious bias,<br />
for all staff including HR and line managers involved in the recruitment, selection and<br />
appointment process.<br />
6. Managers modelling of good EDI behaviours and practices:<br />
Whilst it is clear that there is generally some training provision for staff and managers around<br />
EDI, our findings suggest that this is not translating into perceptions of a consistent modelling of<br />
good EDI behaviours and practices by managers. We suggest the following;<br />
a) If not recently undertaken, a review of the impact and transfer of learning to the<br />
workplace from the EDI learning interventions.<br />
b) A potential redesign/introduction of EDI management skills development<br />
programmes, with a focus on leading diverse teams, engaging with diverse<br />
communities, and championing diversity and inclusion.<br />
c) To increase understanding of what good EDI management is in practice, the<br />
organisation should articulate the specific behaviours that underpin its corporate<br />
values statement.<br />
d) Consideration is given to how the organisation visibly reinforces and rewards managers<br />
and work areas that are consistently displaying good EDI behaviours and practices that<br />
deliver improved service.<br />
e) Senior Managers have EDI objectives built into their performance plans.<br />
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5.2. Outcomes from the Integr8 <strong>NHS</strong> process<br />
Comments received from the Boards include:<br />
“<strong>The</strong> work of Integr8 with the Board has led to demonstrable increase in the<br />
understanding and application of EDI issues. <strong>The</strong>re is now a common approach to<br />
becoming effortlessly inclusive”.<br />
“<strong>The</strong> development intervention has been very powerful in enabling the Board to critically<br />
evaluate its leadership and behaviours and has facilitated a prioritisation of key changes<br />
which are required to achieve a step change in delivery. As a result the board anticipates<br />
that they will see an improvement in its D&I performance over a longer period of time as<br />
objectives are delivered.”<br />
Some of the specific outcomes from the Integr8 <strong>NHS</strong> process for the different boards include:<br />
Strategic Priorities<br />
1. One Board developed a shared understanding of its vision for EDI, around the theme of<br />
“Caring, Fair and Inclusive” and has agreed an action which starts the process of developing<br />
a deeper understanding of the practical application of the vision, supported by simple<br />
messages, a revised value statement and a strategy with clear outcome based objectives.<br />
For another Board, <strong>The</strong> Development Workshop enabled the Executive Team to have critical<br />
discussions about the EDI Vision and the road to exemplar. This enabled the Board to<br />
further embed their shared vision to become “effortlessly inclusive” and to tie this in with<br />
the values of the Trust.<br />
2. Identification of objectives to improve the integration of EDI into strategic governance,<br />
business planning and scorecard. This combined with work on the EDI strategy, next year’s<br />
business planning cycle and performance measurement is expected to improve the<br />
underlying links between strategic planning and EDI.<br />
3. One Board has already identified the gaps in available patient data and put plans in place<br />
for <strong>2010</strong>-11 to start to improve the availability and analysis of patient data.<br />
4. <strong>The</strong> intervention has had an important impact in raising awareness of the need to<br />
integrate EDI into leadership and management. Many of the objectives identified as a<br />
result of the intervention are focused on improving sustainable engagement with the<br />
agenda. <strong>The</strong>se include steps to integrate EDI into core business planning processes, training<br />
interventions for managers and a review of the strategy and values of the Trust to ensure<br />
simplicity of message. <strong>The</strong>se are to be promoted through Trust events and FT consultation.<br />
<strong>The</strong>se steps should improve engagement with the agenda, particularly from middle<br />
managers and leaders and should over time improve the Trusts performance in this area.<br />
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5. <strong>The</strong> development intervention enabled one Board to crystallise its understanding of the<br />
links between EDI and its strategic priorities. <strong>The</strong> development of its scorecard, which<br />
embodies the strategic priorities of the Trust, has provided a powerful opportunity to<br />
mainstream EDI into these strategic priorities. <strong>The</strong> planned actions to further clarify the EDI<br />
elements within the scorecard should further enhance the understanding of the core<br />
business case. For a second Board, as a result of the work with Integr8, Board members are<br />
more aware of how their EDI vision and objectives are linked to strategic <strong>NHS</strong> Priorities.<br />
Effective Governance<br />
6. Two of the Boards recognised that the role and influence of their E&D Steering<br />
Group/Committee could be strengthened and also that there needs to be clarity on the<br />
EDI responsibilities of all Board Committees. A review of the current governance<br />
arrangements has been included in one of the Board’s agreed action plan.<br />
7. For one Board, the Development Workshop led to a more consistent approach in terms of<br />
application and commitment from Board level downwards. <strong>The</strong> Trust’s Workforce<br />
<strong>Diversity</strong> Group reviewed its terms of reference and has re-named itself Staff Engagement<br />
Group. <strong>The</strong> membership of this group cuts across all areas of the organisation and includes<br />
representation from the different staff diversity groups.<br />
8. It is anticipated that changes to governance and planning arrangements will naturally lead<br />
to appropriate EDI risks being identified. At present the Risk Register and Board Assurance<br />
documentation are being reviewed.<br />
9. Following the intervention all the Boards are keen to ensure that an EDI focus becomes<br />
better embedded in normal business, although they continue to recognise the value of<br />
specific EDI agenda items where appropriate. Actions identified to embed EDI into business<br />
planning & scorecard and to strengthen governance should help to raise the profile of EDI<br />
issues on the agenda and to improve the understanding of the Board in challenging and<br />
maintaining a focus on EDI.<br />
10. <strong>The</strong> intervention has helped to raise awareness with the Boards of their role in critically<br />
evaluating EIAs. In addition the actions identified to improve governance and the visibility<br />
of EDI in strategic drivers, is expected to improve engagement with the EDI agenda through<br />
normal business.<br />
Priority actions<br />
11. <strong>The</strong> intervention has raised the profile of D&I in the workforce and with the Board; in<br />
addition actions to improve workforce understanding through simple messages and values<br />
will help to improve inclusion and diversity. <strong>The</strong> Boards will also continue to focus on<br />
different workplace inclusion initiatives, including engagement with staff over internal<br />
communications, development of staff networks and positive action initiatives to improve<br />
representation at all levels.<br />
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12. Work continues to develop Organisational Values and associated values both to address<br />
workforce D&I issues and to enhance patient experience.<br />
13. <strong>The</strong> intervention has helped to raise the commitment and profile of existing plans to<br />
impact assess service delivery, implement patient diversity monitoring and specific<br />
initiatives to deliver improvements for specific patient groups.<br />
14. One Trust’s 3 <strong>Diversity</strong> Groups (Deaf & Disability, Cultural <strong>Diversity</strong>, and LGBT) have<br />
revised their terms of reference to become forums that work with front-line staff to<br />
increase inclusion and diversity.<br />
<strong>Leadership</strong><br />
15. EDI knowledge and understanding has been enhanced further through the development<br />
intervention. Also, a greater understanding of collective leadership has been developed<br />
and a commitment to increase the visibility of EDI on the Board agenda.<br />
16. In addition, the Board Development workshop has given more confidence to members<br />
around EDI that has enabled them to start asking more difficult questions about EDI issues.<br />
17. One Board has recognised the need to refresh its focus on EDI issues and to move to more<br />
outcome based approach to delivery. <strong>The</strong> actions identified to improve governance and to<br />
create a clearer strategic approach are intended to create a sustainable approach to EDI.<br />
18. <strong>The</strong> development received has reinforced good D&I behaviours on the Board. <strong>The</strong><br />
intervention has also helped to improve the working of the Board because it has contributed<br />
to a greater understanding of the value of difference, leading to a positive recognition of the<br />
benefits of celebrating inclusiveness in delivering services but also in maximising Board<br />
effectiveness.<br />
19. Board members have identified individual and collective strengths and areas for<br />
development as inclusive leaders. Board Members were also able to use these insights to<br />
develop personal actions to enhance their confidence and competence as inclusive leaders.<br />
Organisational Shift<br />
20. An initial set of objectives has been identified which are mainly focused on addressing the<br />
gaps in strategic leadership and governance. <strong>The</strong>se objectives include the need to<br />
establish a clear strategy and values. <strong>The</strong> process for developing these will review all the<br />
available data, consultation feedback and the outcomes of the development intervention to<br />
provide clear outcome based objectives for the Trust to take forward.<br />
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21. <strong>The</strong> Transformation Team are now embarking on a change programme that will further<br />
embed Kings Values and will define a set of behaviours, the “Kings Way”. <strong>The</strong>se<br />
behaviours will be modelled across the Trust, from Board level downwards.<br />
22. <strong>The</strong>re has been a tangible increased discussion, communication and involvement with the<br />
local community and other diverse groups regarding service developments.<br />
23. Many of the objectives and priorities which have emerged from the intervention were<br />
known already but the intervention has helped to crystallise these and also to identify<br />
some of the key issues of EDI leadership for the Trust.<br />
24. For the <strong>NHS</strong> NW the focus is on legacy. <strong>The</strong> preliminary proposal is to use the <strong>NHS</strong><br />
NorthWest regional E&D forum to disseminate key learning from their approach to<br />
embedding EDI into the work of the Board and across the <strong>NHS</strong> system. <strong>The</strong> intention is to<br />
ensure that progress, knowledge and skills gained from leading on the EDI agenda are<br />
captured and preserved as the transition to the new <strong>NHS</strong> model of GP consortia emerges.<br />
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6. Key Learning<br />
1. Benefits to Participating Trusts<br />
a. Improved Governance: <strong>The</strong>re is a renewed focus on vision, mission, and strategic<br />
planning for EDI, and a focus on capturing EDI objectives, activities, measures and<br />
outcomes into easy to track, monitor and scrutinise Board level scorecards to improve<br />
collective governance.<br />
b. Inclusive <strong>Leadership</strong>: <strong>The</strong> use of the Factor 8 Different Leaders Assessment Tool and the<br />
supporting coaching is leading to heightened awareness and understanding of Inclusive<br />
<strong>Leadership</strong> both at individual and collective board member level, and the development<br />
of personal action plans to increase competence and confidence.<br />
c. Exemplar High Performing Inclusive Organisation benchmark: Providing Board<br />
members with a shared frame of reference for where they are now and where they are<br />
trying to get to has accentuated a sense of collective ownership, purpose and direction<br />
for EDI, and catalysed momentum for further change.<br />
d. Changing behaviours: Recognition and emphasis on living the value of inclusion, has led<br />
to further focus on embedding behaviours, going beyond strategy, process and structure<br />
to deliver meaningful EDI outcomes and improved performance.<br />
2. Project Lessons<br />
a. OD & Change methodology: Adopting a change strategy approach to EDI and the<br />
Integr8 <strong>NHS</strong> process has greater resonance and more impact. In other words, it is<br />
important to get the Boards to view the intervention not just as an opportunity to learn<br />
more about EDI, but as part of a change process to propel the Trust further along the<br />
journey to exemplar EDI status.<br />
b. Align to local context: <strong>The</strong> approach to EDI is a function of the local context, so Integr8<br />
<strong>NHS</strong> is flexed to align with Board culture and specific needs of each Trust. This was<br />
particularly evident with <strong>NHS</strong> NW where the emphasis rightly shifted to legacy learning<br />
and embedding of good practices.<br />
c. Focus on the role of the Board: while ultimately the aim is to see improvements in<br />
workforce, workplace diversity and inclusion issues and in patient care and community<br />
connection, for this intervention to be successful the focus needs to be on the Board of<br />
itself, governance of EDI issues such as strategy, performance monitoring, effective<br />
scrutiny and constructive challenge. It is by “stepping up its game” as the ultimate<br />
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leaders of EDI in the Trust, that the organisation will achieve the broader goals it has set<br />
itself.<br />
d. Project Duration: <strong>The</strong>re needs to be an appropriate and adequate timeframe<br />
established for the implementation of the project and the delivery of its outcomes.<br />
<strong>The</strong>re was a sense at times when we and the Trusts felt that we were going through<br />
parts of the project too quickly to have the maximum potential impact. A project of this<br />
nature particularly needs more time post the development workshop and Board<br />
agreement to the action plans, for meaningful implementation before review of the<br />
outputs.<br />
3. EDI <strong>The</strong>mes<br />
a. Culture Change Challenge: Translating EDI policies, processes and structures into<br />
sustained behavioural and cultural change in the organisation is the biggest challenge<br />
that organisations face. It requires consistent and sustained focus on the part of the<br />
Boards to ensuring that this is achieved.<br />
b. Effective Scrutiny: <strong>The</strong> breadth and depth of effective leadership and scrutiny of EDI by<br />
the Boards is variable.<br />
c. EDI <strong>Leadership</strong>: <strong>The</strong>re is a tendency on the Boards for EDI to be de facto the preserve of<br />
a few members.<br />
d. Process Driven: <strong>The</strong>re is an over-reliance on processes such as Equality Impact<br />
Assessments and Single Equality Schemes, rather than robust challenge and innovative<br />
thinking by the Board.<br />
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7. Conclusions and recommendations for the future<br />
<strong>The</strong> Integr8 <strong>NHS</strong> process has proven to be a powerful vehicle for enabling a Board to take stock<br />
of where they are on the journey to becoming an exemplar high performing inclusive<br />
organisation. <strong>The</strong> process provided Board members with personal and collective insight into how<br />
to become even more effective at embedding EDI into governance and ensuring clear linkages<br />
between EDI and the vision and business strategy for their organisation. With the passage of<br />
time and a sustained effort on the part of the participating organisations we expect to see<br />
progress in the way they for example:<br />
- commission for inclusion<br />
- deliver inclusive health and health care services<br />
- engage patients, carers, the general public, local populations inclusively<br />
- lead inclusively<br />
- recruit for inclusion and diversity<br />
- manage for inclusion and diversity<br />
- harness innovation from inclusion and diversity<br />
- harness productivity and quality improvement from inclusion and diversity<br />
- improve prevention through inclusion<br />
However for this approach to fully deliver the desired outcomes our views are that:<br />
1. A one-off intervention can address some of the EDI issues that the Board may face, but for<br />
sustainable impact further support by way of coaching at Board level and possibly at subcommittee<br />
level as well as external accountability is needed.<br />
2. <strong>The</strong> timeframe for a project of this nature to fully deliver on its objectives should be 12 to 18<br />
months minimum. This would give sufficient time for measurable outcomes to become<br />
evident.<br />
3. <strong>The</strong> facilitation of an intervention like this requires expertise in EDI, change management,<br />
strategic thinking as well as experience and well-developed skills in group facilitation at<br />
Board level.<br />
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