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North Hampshire Clinical Commissioning Group

January 2015

Equality Delivery System ReturnThe equality delivery system is a national tool, designed to help local NHS organisations to review and improve the services they provide for their local communities, consider health

inequalities in their area and provide better working environments, free of discrimination, for those who work in the NHS.

EQUALITY DELIVERY SYSTEM – JANUARY 2015

Evidence against 4 goals and 18 outcomes of the Equality Delivery SystemThe North Hampshire CCG evidence for the January 2015 is illustrated in the below table.

GOAL EVIDENCE EVIDENCE DOCUMENTSSELF ASSESSED GRADE

Suggested action to improve grade/ enhance compliance with ESD

1. Better Health Outcome1.1Services are commissionedprocured, designed and delivered to meet the health needs of local communities

North Hampshire CCG (NHCCG) commissioning priorities are based on evidence within the Hampshire Joint Strategic Needs Assessment (JSNA) which highlights local health needs and key areas of inequality. The JSNA includes data on age, deprivation, un-employment, inequalities mental health, lifestyle and vulnerable people. The commissioning priorities are also fed by the health needs assessment.Specific needs assessments are conducted relevant to the strategic priorities of NHCCG.NHCCG is a member of the Health and Wellbeing Board that is also attended by other health partners, the aim of the Board is to jointly work on the JNSA strategy.

NHCCG aims for its providers, through contracts and service level agreements, to ensure that patients are at the heart of service redesign and delivery. In partnership with providers NHCCG shapes the contracts ensuring that services commissioned, designed and procured meet the health needs of local communities, promote wellbeing and reduce health inequalities. NHCCG is currently able to aggregate performance data by age, sex (gender), race and some disabilities, and pregnancy and maternity.

NHCCG and Hampshire County Council Adult Services have continued to working together, with common aims and principles to commission complementary services and achieve better coordination of services for older people and people with long term conditions. Equality is a key consideration within this and all services within the Integrated Care Programme will respond positively to the needs of diverse individuals, specifically needs.

NHCCG has engaged with the local population on our five year strategy. The CCG asked Hampshire Wellbeing Services to undertake a consultation exercise with marginalised residents to seek their views on the North Hampshire CCG five year strategy. The report is included in the evidence documents column.

NHCCG clinical services procurement strategy includes the requirement that we will have regard to the NHS Constitution and the duty to offer choice to patients and sets out that we will engage with service users, local communities, using mechanisms such as the CCG Stakeholder and Communication Committee, Patient Advisory Groups and Healthwatch.NHCCG and Hampshire County Council jointly fund posts for community development officers whose main focus is to establish relationships with the public via existing forums. Some of the work in 2014/15 has focussed on the

Hampshire JNSA:http://www3.hants.gov.uk/factsandfigures/jsna.htm

Dates Governing Body meetings:http://www.northhampshireccg.com/page1.aspx?p=7&t=1

Governing Body papers:http://www.northhampshireccg.com/page1.aspx?p=7&t=1

5 year strategy engagement:http://www.northhampshireccg.com/website/X00237/files/15a._Communications_Update.doc

Hampshire County Council equality team:http://www3.hants.gov.uk/adult-services/adultservices-professionals/aboutas/structure/inclusionandengagement.htm

Alton Strategic review update to Governing Body:http://www.northhampshireccg.com/page1.aspx?p=7&t=1

Healthwatch update

Developing Develop diabetic education access for deprived patient groups.Hold a patient feedback forum has been set up to take place in February 2015 for diabetic integrated services

NHCCG to identify further links with the voluntary sector and establish working relationships

The maternity services contract 2015/16 to include specific requirements around vulnerable groups.

Tier 2 service specifications (services provided by specialist doctors within a community setting for example dermatology clinics) will have specific requirements included to improve access for vulnerable groups.

A review of the joint CDO posts to take place as part of re-arranged funding at Hampshire County Council.

To ensure stakeholder group participation remains a key focus in the discussions on the future direction discussion for Alton health services.Alton Stakeholder Reference Group meeting to be held 4 February 2015 and to continue as identified.

Head of Communications to continue to engage with local patient representative groups and Healthwatch to share views with CCG staff.

Continue the work commenced during 2014/15 in relation to the Nepali and

Equality Workforce Report January 2015 I Page 1 of 15

http://www.northhampshireccg.com/page1.aspx?p=7&t=1



http://www3.hants.gov.uk/adult-services/adultservices-professionals/aboutas/structure/inclusionandengagement.htm



http://www.northhampshireccg.com/website/X00237/files/15a._Communications_Update.doc









http://www3.hants.gov.uk/factsandfigures/jsna.htm





Nepali and Travellers communities.

NHCCG has established quarterly meetings with Healthwatch to discuss work streams and to hear about patient experience from feedback that Healthwatch received and gathered relating to North Hampshire area.

NHCCG meets on a quarterly basis with equality and diversity leads of the other Hampshire CCG’s and Hampshire County Council.

The Head of Communications & Engagement has joined the local Black and Minority Ethnic (BME) forum and attends their meetings regularly.

NHCCG draws on CQC and other national patient surveys to seek views on the satisfaction of patients with services commissioned by NHCCG.The Family and Friends Test for acute services inpatients, emergency department and maternity services information is considered for services provided by Hampshire Hospital NHS Foundation Trust.

The CCG has commenced a review of the health services provided in Alton and a launch event was held 16 July 2014. The CGG has established a patient reference group which will be meeting on 4 February 2015.

The NHCCG Chief Operating Officer has provided interviews to BBC radio Berkshire on six occasions during 2014. Topics that were discussed were Alton Health Strategic Review, HHFT front door and IVF. Interviews were also provided to Radio Breeze about preparation for winter and a self-help book for new mothers. Additionally interviews were provided to Basingstoke Gazette on topics such as difficulty in recruiting and retaining GPs and “Help us Help you” campaign.

NHCCG holds the Governing Body meeting in public every other month. The location for public meetings is rotated across the patch and published on the CCG website. The meeting papers are made available on the NHCCG website.

In preparation for the 2015/16 quality indicators contracting round NHCCG conducted a very small scale survey with people of the local community to ensure that the patient views are incorporated wherever possible in the quality indicators developed for local providers of inpatient care. The survey was completed by members of the CCG Patient Participation Group and the Link & Engagement Partnership meeting. These members were encouraged to share the survey with members of their local Patient Participation Groups.

NHCCG, as part of the knee and hip replacement pathway, held three pathway workshops (September 2013, November 2013 and January 2014). These

http://www.northhampshireccg.com/website/X00237/files/15a._Healthwatch_Hampshire_Update_May_2014.pdf

Communication Governing Body Paper - Black and Minority Ethnic (BME) Wellbeing Action Plan:http://www.northhampshireccg.com/website/X00237/files/10a.%20Communications%20Update%20for%20December%202014.pdf

travellers communities.

Continue to work with Hampshire County Council Inclusion and Engagement Team and Equality and Diversity Leads of other CCG’s.

Explore and if appropriate expand the local survey to inform the development of contract quality indicators for commissioner services.

Continue the work commenced in relation to emergency hospital admissions for urinary tract infections and hydration.


http://www.northhampshireccg.com/website/X00237/files/10a.%20Communications%20Update%20for%20December%202014.pdf









workshops were attended by patient representatives.A patient survey was conducted as part of the service review of the GP front door service at North Hampshire Hospital. The information from the survey was utilised as part of the review of the service.

The NHCCG Clinical Cabinet received an analysis of emergency admissions to North Hampshire Hospital for patients admitted with a urinary tract infection or a fall. The data was broken down by gender, age and geographical location and no specific group was highlighted by the report. Following discussion of this analysis actions were identified to work with Care Homes on hydration and for North Hampshire Hospital to undertake an audit in relation to hydration.

Engagement with young people – North CCG. In 2013 NH CCG piloted a young people’s engagement model, where five students from local schools undertook training and project work in health and commissioning related areas. The success of the pilot has led to the development of a more expansive programme for 2014 which is being delivered in partnership with SCAS, and supported by volunteer coordinators that have been recruited from Reading University.

1.2 Individual people’s health needs are assessed and met in appropriate and effective ways

North Hampshire CCG (NHCCG) commissioning priorities are based on evidence within the Hampshire Joint Strategic Needs Assessment (JSNA) which highlights local health needs and key areas of inequality. The JSNA includes data on age, deprivation, un-employment, inequalities mental health, lifestyle and vulnerable people. The commissioning priorities are also fed by the health needs assessment.

NHCCG aims for its providers, through contracts and review meetings, to provide services that are informed by effective and inclusive health assessments of its patients. Commissioning contracts require that health needs are assessed on the grounds of age, gender and where possible ethnicity. Requirement for a patient satisfaction survey are now also included in the 2014/15 contract service specifications for respiratory and out of hours services.

Engagement with stakeholder groups is ongoing and during 2014 liaison with a number of individual practice patient groups took place. The CCG continued to host the Link Engagement Partnership Group.The CCG is supporting the development of further patient participation groups to support patients to give them the knowledge and skills to challenge the delivery of primary care. One patient from each practice is invited to attend the group and to ensure patient’s voices are heard.

NHCCG developed a Primary Eye Care Assessment and Referral Service. Part of the service included the invitation for patients to complete a patient experience survey at each appointment. This information received from patients via the survey will be incorporated in the services review in March 2015.

Hampshire JNSA:http://www3.hants.gov.uk/factsandfigures/jsna.htm

Add BME action group improving access information from Anne

Communications update Governing Body paper -wellbeing guide:http://www.northhampshireccg.com/website/X00237/files/10a.%20Communications%20Update%20for%20December%202014.pdf

IVF engagement report:http://www.northhampshireccg.com/website/X00237/files/9c.%20IVF%20SHIP%20Engagement%20Report%20North

Developing The pilot project regular attendees to actively seek out patients that may benefit from the service. To ensure that the pilot review includes seeking views of patients that have used the service.

Continue scoping work with Hampshire County Council Public Health department to explore which people attend the Emergency Department at North Hampshire Hospital in Basingstoke and explore reasons why.

Commence further work to engage with community and develop role of health trainer.

Engage further with the Buckskin community in relation to flooding.

Review the wellbeing guides related to the pilot in April and July 2015 to establish effectiveness and identify the potential expansion of the pilot.

Review/analyse the Gypsy and Travellers Equality Workforce Report January 2015 I Page 3 of 15

http://www.northhampshireccg.com/website/X00237/files/9c.%20IVF%20SHIP%20Engagement%20Report%20North%20Hampshire%20FINAL%20Nov%2014.pdf










The CCG is working with the Community Development team in Basingstoke & Deane Council to support their work on community health trainers. This has started with the innovative projects led by the community. Further work is taking place to ensure that the benefits of the work are understood and that development continues to meet the needs of the local community.

NHCCG are supporting a pilot in two practices. The pilot project aims to support GP practices with patients that are regular attendees but do not need further medical support. The pilot initially aims to include patients diagnosed with long term conditions such as COPD, diabetes and mild/moderate mental health.The pilot is a joint initiative between Basingstoke Voluntary Action and the CCG, made possible by grant funding under the ‘Building Health Partnerships’ programme funded by the Department of Health.

NHCCG Head of Communications is a member of the BME action group. As part of the group NHCCG are leading on improving access to services for people of the BME community.

NHCCG, as part of the wider Hampshire CCG’s, has participated in a review of Gypsy and Travellers community health. NHCCG has received the review report and is in the process of analysing the report and identifying the level of need in our CCG area and to identify plans accordingly.

Following the floods in 2014 the CCG and Hampshire County Council Public Health department have engaged with this community in Buckskin to ensure that their health needs are understood in case of further flooding.

Last Autumn the CCG launched a booklet to help new parents deal with minor ailments in their babies and young children. The booklet is given to all new parents by the Health Visitor at the ‘new birth’ visit

NHCCG has started work with Public Health Hampshire County Council to explore which people attend the Emergency Department in Basingstoke and why. The scoping work is aimed to support, where required, communities that utilise Emergency Department service when another service may be more appropriate to use.

NHCCG and Public Health are developing a care pathway for smoking prior to surgery to ensure that all people are able to achieve the best possible outcomes from surgery.

%20Hampshire%20FINAL%20Nov%2014.pdf

community health report and identify the level of need in our CCG area and to identify plans accordingly.

Ensure that patient feedback is included in the Primary Eye Care Assessment and Referral Service review due in March 2015.

Continue and review the pilot project focussed on regular GP attenders.

To ensure the Gypsy and Travellers community health review report is fully analysed and that information identified in relation to the level of need in NHCCG area is incorporated in plans accordingly.

1.3 Transitions from one service to

North Hampshire Clinical Commissioning Group (NHCCG) has included the promotion of partnership working as part of its vision. We place a requirement upon providers to work in partnership to ensure seamless care to our population.

Communication and Engagement Strategy:

Developing Continue to further develop the Integrated Care Teams in North Hampshire.







another, for people on care pathways, are made smoothly with everyone well-informed

Service specifications are developed which clearly specify the service to be provided and these are all subject to an equality impact assessment.

NHCCG has developed a Communication and Engagement Strategy which is to be further developed with increased patient and public insight over the next year. The strategy includes the innovative use of technology and social media such as twitter, Facebook and YouTube. It also includes potential communication methods for communicating and engaging with a wider range of people than has traditionally been done so previously. NHCCG has a ‘Link, Engagement and Partnership Committee’ and we intend to build upon the work of this group going forwards.

NHCCG works with integrated care teams and included comments from special interest groups to inform pathway (re)design. The review of the Hampshire Hospital emergency department front door redesign project included the utilisation of patient feedback from a patient survey.

Work continued in 2014 on the implementation of the ‘diabetes service integration – seamless pathway 1 to 2 and this was completed in October 2014. The pathway design involved patient involvement in 2013 and this specifically looked at the provision of information. Subsequently the design of a webpage was commenced in 2014 however further development is required.The implementation will be followed up with a patient forum in March 2015.NHCCG are working with Diabetes UK South East Regional manager to develop a local North Hampshire diabetic patient event.

http://www.northhampshireccg.com/info.aspx?p=5

Transformation fund paper for people aged over 75:http://www.northhampshireccg.com/website/X00237/files/6a.%20Transformation%20Fund%20for%20the%20over%2075s%20(Revised%20Dec%202014).pdf

Communications Governing Body paper -Front door:http://www.google.co.uk/url?url=http://www.northhampshireccg.com/website/X00237/files/Comms_Update.doc&rct=j&frm=1&q=&esrc=s&sa=U&ei=oo_HVPeqKImR7AbovYHgCw&ved=0CBoQFjAB&usg=AFQjCNEkV1vl2FRzZIEOmZB4DvRP56UKDA

Continue to engage and communicate with relevant health providers to ensure smooth transition is further established.

Further development of the diabetes information website during 2015

Diabetic Patient Forum to be held in March 2015 to explore patient experience with the diabetic pathway.

Continue to work with Diabetes UK South East Regional manager to develop a local North Hampshire diabetic patient event.

1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse

North Hampshire Clinical Commissioning Group (NHCCG) has a zero tolerance to abuse, whether from patients or staff, and we encourage all to report such incidents so they can be thoroughly investigated and acted upon.

NHCCG aims for its providers, through contracts, service level agreements, to deliver harm free services to patients. Specific schedules have been included into contracts setting out requirements on the process of reporting, reviewing and learning from (serious) incidents and safeguarding adults and children concerns.Separate monthly meetings with providers are initiated to discuss serious safety incidents to ensure appropriate learning is identified and actions are implemented to minimise recurrence. We also ensure that we monitor the key risks that relate to specific providers via the contract monitoring process.NHCCG and General Practitioners are a member of the Hampshire Safeguarding Boards for both adults and children and we have employed a designated nurse for safeguarding adults, a designated nurse for safeguarding children and a designated nurse for looked after children.Safeguarding procedures are adhered to and training is provided for all relevant

Quality update Governing Body paper – patient safetyhttp://www.northhampshireccg.com/website/X00237/files/10a.%20GB%20Part%201%20GB%20Quality%20Report%20January%202015%20-%20FINAL.pdf

Safeguarding adults and children strategies and policies:http://www.northhampshireccg.com/info.aspx?p=5

Developing GP practices are required to identify a lead for safeguarding adults and NHCCG will ensure that this is in place.

NHCCG will support the development of a Hampshire wide suicide prevention strategy

To continue monitoring of commissioned services via contracting process on the safety of services provided

To continue supporting the Hampshire Safeguarding Adults Board and sub groups.

To continue supporting the Hampshire Safeguarding Children’s Board and sub





http://www.northhampshireccg.com/website/X00237/files/10a.%20GB%20Part%201%20GB%20Quality%20Report%20January%202015%20-%20FINAL.pdf



http://www.google.co.uk/url?url=http://www.northhampshireccg.com/website/X00237/files/Comms_Update.doc&rct=j&frm=1&q=&esrc=s&sa=U&ei=oo_HVPeqKImR7AbovYHgCw&ved=0CBoQFjAB&usg=AFQjCNEkV1vl2FRzZIEOmZB4DvRP56UKDA



http://www.northhampshireccg.com/website/X00237/files/6a.%20Transformation%20Fund%20for%20the%20over%2075s%20(Revised%20Dec%202014).pdf








staff.NHCCG has safeguarding adults and children strategies and policies in place.NHCCG has a collaborative relationship with the Care Quality Commission and Monitor. Joint quarterly Wessex Quality & Surveillance meetings are held and NHCCG representatives attend this meeting.

NHCCG uses the Governing Body Assurance and Risk Management Framework to keep track of the risks, which include safety concerns, that confront the organisation and to ensure that the proper controls are in place to manage these risks.

NHCCG will strengthen and build upon current processes to gain feedback from its population on the safety of services.

Following a suicide audit undertaken by Hampshire County Council Public Health department joint work with the CCG was commenced to ensure that the needs of vulnerable groups with regard to suicide are understood and preventative measures can be put in place.

The Child Death Overview Panel reviews all child deaths in Hampshire and ensures where appropriate preventative actions are put in place to prevent further deaths.

groups.

To ensure that providers of commissioned services identify learning from serious incidents and safety concerns.

To ensure that providers of commissioned services comply with national Central Alerts System requirements and other national patient safety guidance.

To support in the suicide prevention work led by Hampshire County Council Public Health Department.

1.5 Public health, vaccination and screening programmes reach and benefit all local communities and groups

North Hampshire Clinical Commissioning Group (NHCCG) geographical area comprises of a diverse patient population and over the past year NHCCG has undertaken work to improve the uptake of flu vaccination.

Screening and immunisation services are available to all residents in NHCCG and vaccination programmes and policies are in place for both seasonal flu and policy is in place for pandemic flu. There is a focus on increasing uptake and coverage to increase coverage for those at risk.A group has been set up to review programmes and look at tackling inequalities across Wessex.

Public Health Services are provided to all residents in NHCCG and vaccination programmes and policies are in place for both seasonal flu and policy is in place for pandemic flu.

The Hampshire JNSA identifies that there is a need to improve the uptake of childhood immunisations, basic alcohol screening (identification), cancer screening programmes and for a focus on embedding chlamydia screening in primary care and core sexual health services. There is also a need to develop a consistent approach to screening new entrants for Tuberculosis across the county. To improve the uptake of screening programmes NHCCG, in collaboration with the relevant local organisations, has processes and

Public Health update report:http://www.northhampshireccg.com/page1.aspx?p=7&t=1

Flu vaccination campaign:http://www.northhampshireccg.com/health-campaign.aspx

Developing For 2015 NHCCG will be promoting the uptake of the NHS Health check in partnership with Hampshire County Council Public Health Services.NHCCG will undertake work to increase the uptake in groups that have a lower uptake such as men, and those from deprived areasThe work will be undertaken jointly with Hampshire County Council Public Health, through patient campaigns and engagement with General Practitioners and practice nurses.

NHCCG will continue to promote the uptake of flu vaccination for the North Hampshire population.NHCCG will provide flu vaccination drop in clinics for staff

Hampshire Country Council Public Health jointly with NHCCG will aim to implement


http://www.northhampshireccg.com/health-campaign.aspx









contractual agreements in place which will support the delivery of public health programmes that are accessible and beneficial to communities and groups as a whole, with all contractual agreements reviewed on an annual basis.

Hampshire County Council Public Health have commenced work to smoking inequalities and in specific people that smoke and have mental health concerns.

Work has also commenced to review the efficiency of the diabetes network in North Hampshire and how this can be made accessible for all diabetic patients.

the alcohol nurse services model which will require a partnership approach to commissioning of this pathway.

Hampshire Country Council Public Health jointly with NHCCG will continue the work on smoking inequalities.

Hampshire Country Council Public Health jointly with NHCCG will continue to review the efficiency of the diabetes network in North Hampshire.

2. Improved patient access and experience2.1 Patients, carers and communities are readily access services, and should not be denied access on unreasonable grounds

North Hampshire Clinical Commissioning Group (NHCCG) has an established process of putting together a range of mechanisms such as email, telephone, Facebook and Twitter to actively invite members of the public to let us know where they feel our services are not accessible for people with an increased need.NHCCG website includes a listening to you section where people are encouraged to feedback about health services and also includes a ‘you said we did’ section.

NHCCG is working with leaders of the local Nepalese community to improve access to health services particularly by the senior members of their community to GPs where language is a barrier to communicate.

Basingstoke and Deane Health and Wellbeing Group (B&DHW) have developed a booklet for people that may require explanation of the National Health Service. The booklet signpost people to the services available and includes a section on NHCCG and our role.B&DHW together with NHCCG have held a disabilities forum seeking the views from people on what services we should be commissioning from their perspective.

A review of complaints and concerns received by NHCCG for the period 1 January – 31 December 2014was undertaken in January 2015 and this illustrates the following identified potential adverse impacts (direct or indirect) on groups with protected characteristics:

Race; Direct: Inappropriate questions relating to origins Indirect: Language issues leading to misunderstandings Disability; Direct: OT service for children with sensory issues not

commissioned

Public Health Governing Body paper - Alcohol Nurse Services:http://www.northhampshireccg.com/website/X00237/files/17a.%20PUBLIC%20HEALTH%20REPORT%20January%202015%20FINAL.pdf

Living and working well in Basingstoke and Deane – page 36/37:http://www.basingstoke.gov.uk/Resources/A/A/%7BAA0D7293-398D-4F92-A7F7-1DB6686962CC%7D/Documents/Living%20and%20working%20in%20Basingstoke.pdf

you said we did:http://www.northhampshireccg.com/page1.aspx?p=3

Developing To identify ideas on having better translation services available for people from the Nepalese community to enable more effective communication.

Work to be undertaken with the multi-cultural forum to scope how effective the BME community use NHS services such as 111.

Explore if the local Health and Wellbeing booklet developed by Basingstoke and Deane Health and Wellbeing group can be adopted by other areas in North Hampshire.

To implement a complaints feedback enquiry following closure of a complaint or concern.

To conduct analysis and monitoring of complaints against the nine protected characteristics in the quarterly complaints report.

Hampshire Country Council Public Health jointly with NHCCG will aim to implement the alcohol nurse services model which will require a partnership approach to commissioning of this pathway.


http://www.northhampshireccg.com/page1.aspx?p=3



http://www.basingstoke.gov.uk/Resources/A/A/%7BAA0D7293-398D-4F92-A7F7-1DB6686962CC%7D/Documents/Living%20and%20working%20in%20Basingstoke.pdf



http://www.northhampshireccg.com/website/X00237/files/17a.%20PUBLIC%20HEALTH%20REPORT%20January%202015%20FINAL.pdf






Indirect: Special needs not considered Age; Direct: CCG IVF policy restrictions (not in line with NICE guidance).

Condescending attitude to elderly patient. Indirect: Access to patient transport for elderly. Potential outcomes of Alton

review on elderly. Geographical location; Indirect: Potential outcomes of Alton review due to

location. Temporary lack of mental health services to adults in remote location.

NHCCG is developing the collection of information related to the protected characteristics in relation to complaints, concerns and enquiries received. The number of complaints and concerns received remains low offering little information, however themes have been identified over the last year as identified above.

A new feature ‘Talking Health’ is being sent to all community and parish magazine across the CCG area. Articles relating to health and wellbeing will be sent on a regular basis to these magazines (launch January 2015).

An evaluation of Alcohol Nurse Services in Hampshire has informed the development of a single Alcohol Nurse Service Model to support commissioning against national standards across the local acute NHS hospitals. The model will form part of a pathway for people to access alcohol related services from primary prevention to in patient detoxification. The evaluation identified opportunities to prevent alcohol specific hospital admissions, readmissions and a reduction in bed days.

2.2 People are informed and supported to be as involved as they wish to be in decisions about their care

North Hampshire Clinical Commissioning Group (NHCCG) promotes patient involvement in decisions relating to places of treatment through Patient Choice and through supporting the Choose & Book programme. The local complaints process supports this and enables patients to identify where they have concerns over care/treatment.

NHCCG engages with and consults patients if it is planning to commission changes to services. Further work from these engagements has been identified and these are included in the action column.

CCG consulted with marginalised residents through a series of facilitated meetings on the priorities for the CCG for 2014/15. An action plan was written following these meetings and this is monitored. From this consultation it was identified that there is a need amongst the Nepalese community to have support in accessing GP services.The action plan of the consultation is considered and monitored at the NHCCG Link Engagement Partnership group (LEAP) meeting.

Communications Governing Body paper -IVF consultation:http://www.northhampshireccg.com/website/X00237/files/12a.%20Communications%20Update%20for%20November%202014.pdf

Developing Work with community groups to support marginalised groups to self-care.

Work with the community to provide them with confidence in health care professionalsProgramme of training/information for GP’s on consultation with marginalised groups.Set up a Long Term Conditions patient involvement group in 2015/16.

Monitor progress against the consultation action plan at Link Engagement Partnership group meeting.


http://www.northhampshireccg.com/website/X00237/files/12a.%20Communications%20Update%20for%20November%202014.pdf






2.3 People report positive experiences of the NHS

North Hampshire Clinical Commissioning Group (NHCCG) is keen to ensure that patients that use services, that NHCCG commissions, have an excellent experience. NHCCG set up patient participation groups (ppg) that work out of general practitioners practices and these continued to meet during 2014. The patient participation group aim is to make the patients voice heard by the practice and provide an opportunity for patients to contribute to the continuous improvement of services. The ppg representatives meet jointly at NHCCG every other month and they held their 22nd meeting in December 2014.

The NHCCG Link, Engagement and Partnership group (LEAP) have a standing agenda item for comments and concerns both positive and negative. The NHCCG patient group also identifies three good and three not so good things about what is happening in practice. Feedback from both groups are fed-back and utilised to inform commissioning.

General Practitioners (GP), as part of their GP membership senate, seek patient feedback. A national requirement is for them to introduce the Family & Friends Test January 2015.

NHCCG aims for its providers, through contracts and service level agreements, to measure patient’s experience and to improve services to enhance the experience from complaints, PALs enquiries and survey feedback. Feedback and actions are monitored at quality review meetings.

North Hampshire Clinical Commissioning Group is committed to sharing and exchanging information with patients, public and working partners. We publish newsletters to our website and members of the public can sign up to this so that NHCCG can keep them up to date with local decision making, events and issues.

Quality update Governing Body paper – patient experience:http://www.northhampshireccg.com/website/X00237/files/10a.%20GB%20Part%201%20GB%20Quality%20Report%20January%202015%20-%20FINAL.pdf

Minutes PPG:http://www.northhampshireccg.com/page1.aspx?p=3

Minutes LEAP:http://www.northhampshireccg.com/page1.aspx?p=3

Newsletters:http://www.northhampshireccg.com/page1.aspx?p=5

Developing To ensure patient engagement/involvement is considered in pathway redesign and pathway reviews.

To ensure the views of North Hampshire CCG population are sought and considered in any work relating to NHCCG work.

To ensure that national and local survey outcomes are considered.

To continue to support meetings of the patient participation groups and Link, Engagement and Partnership group.

NHCCG Heads of Communications to continue attending local patient experience forums such as the BME group.

To continue publishing NHCCG newsletters to the NHCCG website.

To continue monitoring of patient experience via contracting routes with providers.

2.4 People’s complaints about services are handled respectfully and efficiently

North Hampshire Clinical Commissioning Group (NHCCG) has robust and open complaints procedures in place which is published on our website alongside the complaints, concerns and compliments policy. The policy was reviewed to ensure that the recommendations from the Clywd review are considered and reflected in the policy and a revised policy is under development. The review included consideration around equality and diversity and how data against the characteristics can be collected.

The CCG treats all complaints and concerns raised seriously, and with respect and compassion. The team is responsive and keeps complainants informed.

NHCCG website has a translation tool to enable translation into any language.

Compliments and Complaints:http://www.northhampshireccg.com/page1.aspx?p=3

NHCCG Complaints report:http://www.northhampshireccg.com/website/X00237/files/10a.%20Complaints%20Report

Developing Complete and ratify the revised complaints policy.

To implement a complaints feedback enquiry following closure of a complaint or concern.

To conduct analysis and monitoring of complaints against the nine protected characteristics in the quarterly complaints report.


http://www.northhampshireccg.com/website/X00237/files/10a.%20Complaints%20Report%20Q2%202014-15%20NHCCG%20FINAL.pdf




















The translation tool is however restricted to translating word documents.

NHCCG provides access to translation services for both those whose first language is not English and the deaf and hard of hearing; this is available on the home page of the CCG’s website.

Any feedback received by NHCCG from service users is taken into consideration for the future of services that we commission. Where relevant feedback is shared with providers through (quality) contracting meetings or direct liaison with the providers complaints team.

%20Q2%202014-15%20NHCCG%20FINAL.pdf

3. A representative and supported workforce3.1 Fair NHS recruitment and selection processes lead to a more representative workforce at all levels

NHCCG ensures that all its Human Resource processes, including the way in which it recruits its staff, are fair and transparent.

NHCCG has a Human Resources Framework in place that refers to compliance with the Equality Act 2010 which has been built in to all employees’ job descriptions.

Staff have their age, gender, marital status, sexual orientation, religion, belief, race and nationality recorded at point of recruitment (through the monitoring form on the NHS jobs website). This data is updated on a regular basis from an annual data update and cleansing exercise. There are no current plans in place to analyse this data in order to give an insight into whether the make-up of NHCCG workforce is as diverse as can be across all grades.

Human Resources policies:http://www.northhampshireccg.com/info.aspx?p=5

NHCCG Human Resource Framework:http://www.northhampshireccg.com/website/X00237/files/HR_00_V1.01_HR_Framework_North_Hampshire_CCG.pdf

Achieving Implement upgraded NHCCG Equality Impact Assessment and review all Human Resource policies against this

3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations

The NHS Job Evaluation Scheme is applied to all posts, ensuring equal pay. We have a clear procedure in place.

National agenda for change profiles are used when undertaking job evaluation as well as the national terms and conditions handbook.The updated 2014 workforce profile will be published on our website.

19% of staff members identified that they were not satisfied with their pay in the 2014 staff survey. An action plan was developed following the survey which will be monitored at the NHCCG Senior Management Committee.

Agenda for change:http://www.nhsemployers.org/agendaforchange

National Job Profiles:http://www.nhsemployers.org/your-workforce/pay-and-reward/pay/job-evaluation/national-job-profiles

Achieving Progress against the NHCCG staff survey action plan will be monitored at the Senior Management Committee meetings.

The second NHCCG staff survey will be conducted in July 2015

3.3 Training and development opportunities are taken up and positively

North Hampshire Clinical Commissioning Group (NHCCG) has made progress in improving training, support and development for its staff.An induction session is available to staff which includes a section on Equality Impact Assessments. 66% of staff have attended the induction session (up to December 2014) and 70% of staff have accessed the Equality and Diversity e-

Workforce profile:http://www.nhsemployers.org/agendaforchange



http://www.nhsemployers.org/agendaforchange



http://www.nhsemployers.org/your-workforce/pay-and-reward/pay/job-evaluation/national-job-profiles






http://www.northhampshireccg.com/website/X00237/files/HR_00_V1.01_HR_Framework_North_Hampshire_CCG.pdf











evaluated by all staff

learning training (January 2015).86% of staff that completed the staff survey 2014 identified that they did undertake Equality and Diversity training

South Commissioning Support Unit launched a revised training catalogue in April 2014 and this includes a range of Equality & Diversity related courses.

A staff handbook was made available to staff and it includes information about appraisal, development and includes a development plan. The staff book also includes a section on ‘valuing diversity and dignity at work’

Online e-learning is available via the Health and Social Care centre and includes training on information governance, records management and information security.

In addition, staff receive regular appraisals with their line manager and are encouraged to enrol on courses that will help them with their professional development.

Training activity is monitored as all activity is recorded through the Oracle Learning Management system.

80% of staff members identified that they received other training, learning or development relevant to their role other than mandatory training (staff survey 2014).

NHCCG does not monitor the attendees on the training and development sessions by equality groups. Furthermore, staff monitoring does not extend to categories of sexual orientation and gender re-assignment

South Commissioning Support Unit:http://southcsu.nhs.uk/what-we-do/human-resources


3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source

North Hampshire Clinical Commissioning Group (NHCCG) as an employer is under a legal obligation of a duty of care to provide both a safe place and safe system of work and within the NHCCG Grievance Policy and Procedure this responsibility is addressed. The CCG also has a whistleblowing policy in place (currently under review) and it encourages all staff to report any incidence of bullying, violence or harassment. On induction all staff receive information about the policy.

Counter Fraud is included in Induction and further programmes were included from April 2014 in the course catalogue. The Course Catalogue includes level 2 Certificate in Equality & Diversity, Conflict Resolution- external trainer training and a bite size session on Bullying and Harassment Awareness.

NHCCG is fully committed to protecting the health, safety and welfare of all its

Human Resources policies:http://www.northhampshireccg.com/info.aspx?p=5

Counter Fraud information: http://www.northhampshireccg.com/page1.aspx?p=11

Workforce profile:http://www.nhsemployers.org/agendaforchange












http://southcsu.nhs.uk/what-we-do/human-resources






staff which is outlined in the Health and Safety policy which sets out how we provide a secure and healthy environment to those that work for the NHCCG.

The staff survey conducted in 2014 identified that in the past 12 months 94% of staff said they did not experience personally any harassment, bullying or abuse at work. An action plan was devised following an analysis of the staff survey and this is monitored at the NHCCG Senior Management Committee.

The CCG buys in a confidential information, advice and support line for employees. This is available 24/7, and calls are free from a landline

Ten (10) new Human Resources polices were subject a 30 day staff consultation in 2014. The development of the policies included the completion of an Equality Impact Assessment which was undertaken by the Commissioning Support Unit. The assessment includes a review against the nine characteristics. Existing HR policies are being reviewed in their normal cycle and a review of the EIA is part of that process.

3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives

North Hampshire Clinical Commissioning Group (NHCCG) is committed to providing working options that are flexible, accommodating and consistent with the needs of the organisation.

NHHCCG has a flexible working policy in place which includes arrangements for carers.Short term changes to working hours are included in the Leave policy

The staff survey conducted in 2014 identified that 80% of staff members felt that the CCG gives due consideration to flexible working. 5.7%of staff members didn’t feel that the CCG gives due consideration to flexible working and 17% neither agreed nor disagreed.

Flexible working policy:http://www.northhampshireccg.com/info.aspx?p=5



3.6 Staff report positive experiences of their membership of the workforce

North Hampshire Clinical Commissioning Group (NHCCG) encourages staff to raise concerns if they believe that their physical or mental health is being adversely affected within the workplace.

NHCCG works with the NHS employers Social Partnership Forum which offers employers in the NHS the opportunity to discuss debate and influence the development and implementation of policies that impact on the health workforce. No concerns have been identified via this forum.

Occupational Health referrals are available for all employees. A member of the occupational health team provides a Wellness Drop In Surgery at the NHCCG premises. The occupational health nurse visits the CCG on a regular basis and they provide work desk assessments, eye test advice wellness clinics, stress

Health & Safety Policy:http://www.northhampshireccg.com/info.aspx?p=5

www.wellness.rightmanagement.co.uk.

Achieving The occupational health representative will attend the NHCCG communications meeting to outline the services they provide

Circulation of occupational health tips directly to NHCCG is due to commence in 2015.


http://www.wellness.rightmanagement.co.uk/

http://www.wellness.rightmanagement.co.uk/










buster sessions and flu jabs.

A confidential manager referred or self-referred staff counselling service is available to all staff.NHCCG supports seasonal campaigns for employees such as flu jabs; this was provided in October 2014.

NHCCG is fully committed to protecting the health, safety and welfare of all its staff which is outlined in the Health and Safety policy which sets out how we provide a secure and healthy environment to those that work for the CCG.

The national NHS staff survey was applicable for CCG staff in 2014 and the results are awaited.

The CSU conducted a staff survey on behalf of NHCCG and the report was discussed at senior management committee. An action plan was developed and progress is monitored at this committee.In the 2014 Staff Survey 97% of staff recommended the CCG as a place to work. An action plan was developed following the survey which will be monitored at the NHCCG Senior Management Committee.

4. Inclusive Leadership4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations

North Hampshire Clinical Commissioning Group (NHCCG) has acknowledged that in services commissioned people may experience inequalities in accessing services or as members of staff.

A review of the Equality and Diversity Strategy (2012) was undertaken and the strategy was discussed at August 2014 Link Engagement and Partnership Group meeting and was presented to the Integrated Governance Committee meeting in October 2014. A staff consultation took place in November and December 2014. The strategy is due to be ratified in January 2015.

The Governing Body does not deal with equality as a separate matter; it is built into all of its policies and procedures, including reporting on equality objectives within the personal development reviews of staff at all levels.

LEAP minutes to Governing Body:http://www.northhampshireccg.com/website/X00237/files/11b._LEAP_Draft_Minutes_11_3_14.doc

Equality Strategy:http://www.northhampshireccg.com/info.aspx?p=5

Achieving The progress against the Equality and Diversity Strategy objectives implementation plan will be monitored on a four monthly basis at the Integrated Governance meeting and a twice yearly updates will be provided to the Governing Body as part of the Equality and Diversity Governance process.

The January 2016 EDS return will be approved by the Governing Body during their January 2016 meeting.

4.2 Middle managers and other line managers support their staff to work in culturally competent ways within a work

The Equality Impact Assessment (EIA) process is starting to embed within the organisation. EIAs are included in 2014/15 provider service specifications and the aim is to ensure that All internal HR policies were reviewed in 2014 and they CSU HR department undertook an EIA on all policies that were ratified.

The Governing Body will ensure that any policies that are ratified include Equality Impact Assessments.

Papers that are presented to the Governing Body and other major committees

Equality Strategy:http://www.northhampshireccg.com/info.aspx?p=5SMC minutes - Staff Survey results paper:http://www.northhampshireccg.com/website/X00237/files/

Developing The revised EIA documentation will be further introduced and implemented during 2015.Any new policy, procedure, strategy, service or function will be subject to the revised EIA process and any document that is due for review will also be included.


http://www.northhampshireccg.com/website/X00237/files/11b.%20SMC%20Minutes%2013th%20November%202014.pdf








http://www.northhampshireccg.com/website/X00237/files/11b._LEAP_Draft_Minutes_11_3_14.doc






environment free from discrimination

have a front page included to them which includes a section on equality and diversity.

An induction session is available to staff which includes a section on Equality & Diversity and Equality Impact Assessments. A course catalogue was launched in April and this includes a range of E&D related courses.

11b.%20SMC%20Minutes%2013th%20November%202014.pdf

A staff guide on the completion of an EIA will be developed and introduced.

EIA training is in the process of being commissioned from South CSU for key staff within the CCG, this will take place early 2015.

4.3 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed

North Hampshire Clinical Commissioning Group (NHCCG) has taken many steps to promote good working environments for staff.

NHCCG is committed to the NHS Constitution and would like all managers to ensure that the workforce is committed to the principles, values and rights within it.

Commissioning Support South facilitate a Staff Partnership Forum with the aim to ensure that the interests of staff and organisations including the Clinical Commissioning Groups are discussed in this group. The group has representatives from Unison. No concerns in relation to NHCCG have been raised to the meeting.

NHCCG has a whistleblowing policy and a grievance policy & procedure in place (currently under review).

NHCCG has undertaken work to develop an Equality Impact Assessment (EIA) and this was launched during January 2015 and presented to the Integrated Governance Committee. Any new policy, procedure, strategy, service or function will be subject to the revised EIA process and any document that is due for review will also be included.

Whistleblowing policy and a grievance policy & procedure:http://www.northhampshireccg.com/info.aspx?p=5

Developing The revised EIA documentation will be further introduced and implemented during 2015.

Any new policy, procedure, strategy, service or function will be subject to the revised EIA process and any document that is due for review will also be included.

A staff guide on the completion of an EIA will be developed and introduced.

EIA training is in the process of being commissioned from South CSU for key staff within the CCG, this will take place early 2015.





