Governance

SAVE ITEM
case-study

27 / 01 / 2009

  • SHA region
  • The organisation
  • What we did and why
  • How we did it
  • The results and next steps
  • Contact details and further information
  • SHA region

    NHS North West

    The organisation

    The Cardiothoracic Centre (CTC) Liverpool NHS Trust was formed in April 1991, as part of the first wave of NHS Foundation Trusts. The Trust has since developed into one of the largest specialist heart and chest hospitals in the UK, providing specialist services across the North West of England, North Wales and the Isle of Man. It employs just over 1,300 staff.

    What we did and why

    The trust developed the SES to demonstrate its commitment to ensuring that equality and diversity is integral to how it operates, at both strategic and operational levels.

    The trust board recognised the clear links between legal compliance and its aim to achieve exemplar status. Equality and human rights were considered central to effective governance across the organisation, as outlined in the Department of Health's Integrated Governance Handbook.

    How we did it

    The Trust employed an external equality and diversity consultancy to carry out a gap analysis of its activities, systems and structures. This identified good practice and areas that needed to be developed, such as governance, workforce support and development, and involvement and consultation.

    The trust used this to prioritise its activities in the SES action plan. The rationale and activity that underpinned the trust's approach included:

    Choosing an SES

    The decision to develop an updated SES was in line with the approach adopted by the Department of Health. Key benefits included:

    • Mirroring the approach of establishing the one Equality and Human Rights Commission
    • Ensuring a coherent and comprehensive approach to equality and diversity within the Trust - avoiding duplication of work for separate schemes
    • Providing a framework for addressing the dimensions of equality and diversity, and current public sector duties

    Governance management

    Initially, equality and diversity sat exclusively within the Workforce, Strategy and Development Committee. However, recognising that it had ultimate responsibility for this area, the trust board created a more robust accountability structure within the organisation.

    Strategic responsibility for:

    • employees would stay with the Workforce Strategy and Development Committee (WSDC)
    • service delivery, with the Clinical Quality Committee (CQC)
    • overseeing the co-ordination and delivery of the SES action plan sat with the Equality and Diversity Steering Group - with regular reports for the board on progress

    In addition, the terms of reference of all committees included a specific objective on equality and diversity.

    Governance framework

    Two publications were used as the basis to embed equality and diversity within the trust's governance arrangements: The Healthcare Commission's Integrated Governance Guidelines and Standards for Better Health. The SES action plan was also cross-referenced to a range of core and developmental standards as well as Core Standard 7e which is equality and diversity specific.

    The results and next steps

    Key results:

    • The trust has made an explicit connection between helping all communities and groups in its SES and contributing to the local and national agenda
    • The SES is seen as the first stage of an ongoing process and provides a framework for the trust to assess the current status of how the organisation operates
    • It will also enhance current practice and continue to identify areas that need a more pro-active approach to equality and diversity
    • Through the implementation of the new governance arrangements board members, including the chair, chief executive officer, director and non-executive directors, understand and are clearly accountable for equality and human rights within the organisation
    • Consultation and involvement ensures that any evidence and feedback informs subsequent action plans

    Next steps:

    To meet the range of equality and diversity standards:

    • Continue to review and update strategic and operational policies and procedures
    • Review, update and equality impact assess other policies, procedures and provisions
    • Approve resources for ongoing equality and diversity work
    • Ensure the new equality and diversity strapline is adopted across the trust and in all its documents
    • Deliver equality and diversity training sessions within a
    • Learning and Development Framework across the trust, to include the board
    • Incorporate an equality and diversity section in the annual report
    • Evaluate, monitor and review progress against the SES action plan

    Contact details and further information

    Amada Oates Amanda.Oates@ctc.nhs.uk

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