Contents
1 Equality delivery system for the NHS
1.1 The equality delivery system reporting template
Implementation of the Equality Delivery System (EDS) is a requirement on both NHS commissioners and NHS providers. Organisations are encouraged to follow the implementation of EDS in accordance EDS guidance documents (opens in new window).
The equality delivery system is an improvement tool for patients, staff and leaders of the NHS. It supports NHS organisations in England, in active conversations with patients, public, staff, staff networks, community groups and trade unions, to review and develop their approach in addressing health inequalities through three domains:
- services
- workforce
- leadership
It is driven by data, evidence, engagement and insight.
The equality delivery system report is a template which is designed to give an overview of the organisation’s most recent EDS implementation and grade. Once completed, the report should be submitted via england.eandhi@nhs.net and published on the organisation’s website.
2 Equality delivery system rating and scorecard
Please refer to the rating and scorecard supporting guidance document before you start to score. The rating and scorecard supporting guidance document has a full explanation of the new rating procedure, and can assist you and those you are engaging with to ensure rating is done correctly.
Score each outcome. Add the scores of all outcomes together. This will provide you with your overall score, or your EDS organisation rating. Ratings in accordance to scores are below.
| Rating | Scoring |
|---|---|
| Undeveloped activity, organisations score out of 0 for each outcome | Those who score under 8, adding all outcome scores in all domains, are rated undeveloped |
| Developing activity, organisations score out of 1 for each outcome | Those who score between 8 and 21, adding all outcome scores in all domains, are rated developing |
| Achieving activity, organisations score out of 2 for each outcome | Those who score between 22 and 32, adding all outcome scores in all domains, are rated achieving |
| Excelling activity, organisations score out of 3 for each outcome | Those who score 33, adding all outcome scores in all domains, are rated excelling |
3 Domain 1 (1 of 2), Doncaster care group learning disabilities
| Outcome | Evidence | Rating | Owner (department or lead) |
|---|---|---|---|
| 1A, patients (service users) have required levels of access to the service | Last year the learning disabilities services were reviewed for EDS2022.
This year we have decided to stay with the LD services but to focus on one aspect of inequality. RDaSH clinical strategy promise 8, The RDaSH5 Research, create and deliver five impactful changes to inequalities faced by our population in accessing and receiving help from our autism, learning disability and mental health services as part of our wider drive to tackle inequality (“the RDASH 5”). Based upon the research, here are 4 of the RDaSH 5
3.1 What do we want to see changed?We want to ensure that all our patients with a learning disability from an ethnic minority background receive an annual health check resulting in a suitable Health Action Plan. The average life expectancy for the population generally is 81 years. A recent national study involving a person with a learning disability showed that:
We deserve better health, health observatory paper (opens in new window) Literature, which has spanned over two decades, has acknowledged that the intersection of ethnicity and disability, two marginalised identities in society, results in compounded discrimination. Such discrimination worsens inequalities in relation to health outcomes and healthcare among people from ethnic minority backgrounds with a learning disability. These existing disparities are due to the social determinants of health, which are further fuelled by discrimination, racism and marginalisation. In turn, people with a learning disability from ethnic minority backgrounds experience poorer access and experiences of healthcare services and poorer health outcomes. Some of the research involving people with lived experience showed issues such as:
There is a clear inequity in life expectancy for people with a learning disability from an ethnic minority compared to the wider population. Overall, we want to contribute to an increased life expectancy for all people with a learning disability, with a focus on those from ethnic minorities where the gap is much starker. 3.2 What solution to the problem are we looking to advance?If we ensure that all our patients with a learning disability from an ethnic minority background receive an annual health check and a health action plan which is owned and delivered, then we can help reduce the risk of shortened life expectancy. In addition, if we focus upon improving the promotion of health screening programmes (for example, cervical screening, bowel cancer screening.) to this part of our community this could also improve reduced mortality. There hasn’t been enough systemic focus on people with a learning disability from minority communities to get their health check and access associated support services. The experience of people with a learning disability from minority communities’ mirrors that of what was found nationally. 3.2.1 Annual health checksAnnual health checks: liaison nurse working closely with GP to confirm the LD register, checks for those not engaging in health check. Referred to HATS, contact made and at GPs I’ve also been asking if they have anyone who is not engaging with these. The offer and confirm is for over 18s, a transition pathway with GP.
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Rachael Deakin, Matron, Learning disabilities and forensic directorate | |
| 1B, individual patients (service users) health needs are met | We don’t know the national and local position on the update of the annual health check AHC. Work is on the way to establish a baseline.
Part of this work is the liaison nurse working with the GP’s who are paid as part of their contract to deliver the AHC to people with LD. The 4 GP target is 60%. Annual health checks, liaison nurse working closely with GP to confirm the LD register, checks for those not engaging in health check. Referred to HATS, contact made and at GPs I’ve also been asking if they have anyone who is not engaging with these. The offer and confirm is for over 18s, a transition pathway with GP. A bid has been put forward to the APC for more resource for example peer support workers to support on a campaign to raise awareness within the community of the issue, particularly ethnic minority communities. The challenges face with this work, national issues compared with local challenges and how we look to solve these. LD and life expectancy and understanding the numbers of people in our communities will require understanding of the children and the adults within our services. |
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| 1C, when patients (service users) use the service, they are free from harm | Health passport, are examples of tools used to keep patients using the service safe. VIP bag.
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| 1D, patients (service users) report positive experiences of the service |
Some milestones in deploying that solution between now and the end of January
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4 Domain 1 (2 of 2), With me in mind (WMIM) service
| Outcome | Evidence | Rating |
|---|---|---|
| 1A, patients (service users) have required levels of access to the service | Mental health needs are on the rise, it is estimated 1 in 6 children have a mental health problem (NHS Digital, 2021). Launched in 2020, WMIM is a mental health support team that focuses on early prevention and intervention. Their aim is to ensure children, young people and their families can access support for mental health and wellbeing. The service works in collaboration with schools, education settings and external services. The mental health lead working within the school can put through referrals by completing a referral form to the WMIM worker.The WMIM is a school-based service. There is a MH lead in the school who takes the lead in making the referral to the WMIM service. The WMIM service covers 71%, this is achieved with extra funding, in other areas coverage from this service can be as low as 50%, the team are seeking funding waves to address this imbalance. The WMIM team offer a universal service to schools, from this, they are able to target those children who may need additional support with their mental health needs. Mental health lead, gathers data on how the student is feeling. This can include aspects that influence and impact on mood, for example, cultural, religion, race and racism, gender. The data should be reflective of the student’s voice and be personalised. The students’ aspects of what is impacting on their mental health and the things that the worker needs to understand and know about the student.
The team are concerned that their data shows that certain groups are not getting the required access to the service. The WMIM service have worked with Sheffield university to focus on a piece of work related to barriers to referring young people from ethnic minority groups to an external mental health service. As part of this work, teachers are asked to take part in a focus group, barriers to referral to BME students, unconscious bias, mis trust unconscious bias are seen as barriers to referrals. Parents also must consent for any intervention and there is a need for professionals to access the medical NHS record. This has been seen by parents concerned about safeguarding, judgments and racism, and lack of understanding of the service. The WMIM service have also worked with the Grounded Research team within RDaSH to understand, “What is young people feeling?” This has been explored through a service evaluation piece of work. 3 focus groups have been formed to include students identifying as LGBTQ+ in secondary schools boys, in secondary school. Non-white and or non-British For the non-white students, 39 students across 4 schools between year 7 to 13 took part. Themes and sub themes perceived or actual, were identified and the notion – should we be doing things differently? On the boys focus group, they were asked “what it is to be a boy, good things, challenges?” The pressures on boys’ mental health, mental health and exclusion from school. Teachers’ views on boys. An educational psychologist was involved in this work.
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| 1B, individual patients (service users) health needs are met | The data shows that of the 10 most diverse schools, access to WMIM is low.
To bridge this deficit a learning and training as been offered to those schools, so far 3 out of the 10 have had that intervention. The training is about bridging culture. Measurement of improvement for the students is through a pre intervention and post mental, score, at the end of the 8 weeks, qualitative and quantitative feedback, whole school approach.
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| 1C, when patients (service users) use the service, they are free from harm | Referrals criteria and protocols are in place to maintain safety and free from harm for the student. The students are referred that are low level risks, there is no evidence of self-harming. Students and the WMIM practitioner can get in touch with each other outside the weekly session. Parents, and school staff, liaise with the service to ensure that any changes to the student that may affect the intervention is passed on in a confidential manner.
The WMIM practitioner has safeguarding supervision, individual and group by a specialist advisor in safeguarding to ensure safe practice, learning takes place. Part of this learning takes place through different skill sets that make up the WMIM team, bringing different perspectives. The WMIM team are aware they are mostly white practitioners and that students have said they would like someone who looks like them to work with. The team are addressing this through recruitment? and more volunteers, from a protective characteristic Cultural exchange days are hosted by the team, where parents and school staff are encouraged to wear traditional dress. This is an attempt to engage parents who would not traditionally use the service for their child and to break down some of the stigma associated with mental health concerns within marginalised communities. Literature is translated into the main community languages. Interpreters are used if students need it. Interpreters are used for parent led interventions for primary school, children where the first language is not English. Here parents are given strategies to support their children, over an 8-week programme. The team aim to make a video promoting the service in incorporate parents, staff video from diverse backgrounds.
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| 1D, patients (service users) report positive experiences of the service | Rotherham Doncaster and North Lincolnshire interventions EDI stuff
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5 Domain 2, workforce health and well-being
| Outcome | Evidence | Rating | Owner (department or lead) |
|---|---|---|---|
| 2A, when at work, staff are provided with support to manage obesity, diabetes, asthma, COPD and mental health conditions | Weight management support (opens in new window) (staff access only) As part of the trust’s health and wellbeing offer, we have 3 offers to support colleagues in their weight management journey.
RDaSH offers free physical wellbeing activities (staff access only) (opens in new window) across the trust.
Diabetes, Asthma and COPD:
Mental health conditions:
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| 2B, when at work, staff are free from abuse, harassment, bullying and physical violence from any source | As an organisation RDaSH have policies in place for “acceptable behaviour” and measures are in place to address any form of bullying, discrimination, victimisation that may be inflicted by or to any of our colleagues. | ||
| 2C, staff have access to independent support and advice when suffering from stress, abuse, bullying harassment and physical violence from any source | Employees have access to confidential and impartial support via our employee assistance programme via Vivup (opens in new window) (staff access only), this includes support and advice when suffering from stress, bullying, harassment and physical violence from any source.
Staff can also access support through:
The Employee resilience company (TERC) (opens in new window) (staff access only) is providing an on-site counsellor at Tickhill Road Hospital every Friday. |
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| 2D, staff recommend the organisation as a place to work and receive treatment |
2023 staff survey results indicate that:
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6 Domain 3, inclusive leadership
| Outcome | Evidence | Rating | Owner (department or lead) |
|---|---|---|---|
| 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 | All board members in line with the requirements of the NHS People Delivery Plan’s High Impact Action’s (HIA’s) now have specific EDI actions to account for within their job specifications which must be evidenced in their annual PDR’s.
All colleague network groups have an Executive sponsor who feeds back to the board monthly |
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| 3B, board or committee papers (including minutes) identify equality and health inequalities related impacts and risks and how they will be mitigated and managed | All committee paper’s have a cover sheet with an EDI risk rating which is mandatory to complete | ||
| 3C, board members and system leaders (band 9 and VSM) ensure levers are in place to manage performance and monitor progress with staff and patients | WRES and WDES annual reports are submitted on an annual basis.
WRES and WDES action plans are approved by board of directors and updated and monitored on a quarterly basis. Annual colleague inclusion network report submitted on activity. Quarterly EDI activity report submitted |
7 Overall rating
EDS organisation rating (overall rating).
Organisation names: Rotherham Doncaster and South Humber NHS Trust.
Those who score under 8, adding all outcome scores in all domains, are rated undeveloped.
Those who score between 8 and 21, adding all outcome scores in all domains, are rated developing.
Those who score between 22 and 32, adding all outcome scores in all domains, are rated achieving.
Those who score 33, adding all outcome scores in all domains, are rated excelling.
Document control
- Name of organisation Rotherham Doncaster and South Humber NHS Trust.
- Organisation board sponsor or lead: Carlene Holden, Executive Director of People and Organisational Development.
- Name of integrated care system: South Yorkshire ICB.
- EDS lead: Shirley Kirkland and Amanda Ambler
- EDS engagement date: Peer review, 21 February 2023.
- Organisations:
- partnership (two or more organisations): The Rotherham NHS Foundation Trust, Doncaster and Bassetlaw Hospitals, Barnsley NHS Foundation Trust
- integrated care system-wide: South Yorkshire ICB
- Date completed: February 2024.
- Month and year published: March 2024.
- Date authorised: March 2024.
- Revision date: March 2025.
Page last reviewed: April 22, 2025
Next review due: April 22, 2026
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