The EDS Reporting Template

The EDS 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 [email protected] and published on the organisation’s website. 

Executive Summary

The purpose of this report is to provide an overview of the EDS assessment undertaken by the Trust in December 2024 (Domains 2 & 3) & January 2025 (Domain 1). The evidence considered as part of the EDS assessment is summarised in this EDS Reporting Template with and more information is set out in the EDS Evidence Pack available on the NWAS website.

The EDS is a system that helps NHS organisations improve the services they provide for their local communities and provide better working environments, free of discrimination, for those who work in the NHS, while meeting the requirements of the Equality Act 2010. The implementation of this framework by NHS provider organisations is mandatory as per the NHS Standard Contract, It is driven by data, evidence, engagement and insight.

The EDS comprises of eleven outcomes spread across three Domains, which are:

• Domain 1: Commissioned or provided services
• Domain 2: Workforce health and well-being 
• Domain 3: Inclusive leadership.

ASSESSMENT OF DOMAIN 1

Domain 1 considers whether services delivered by an organisation are informed, developed and planned in a way which meets the needs of the communities which are served. The EDS guidance expects that the services assessed in this Domain are mutually agreed with the ICB. However, as NWAS is a unique organisation with the Lancashire & South Cumbria area, the ICB was content with the trust autonomously identifying the area(s) of focus for review. The same dispensation was made for Lancashire & South Cumbria NHS Foundation Trust, while all the acute trusts in this area are working collaboratively with the ICB on a maternity theme. 

The service/areas to be assessed as part of Domain 1 were NWAS Public Health, Cardiac Outcomes Project, Patient Safety and Friends & Family test. The assessment for Domain 1 took place on 9 January 2025 via MS Teams, with a panel comprising of Patient and Public Panel members and Community First Responders volunteers.

Colleagues who had submitted their evidence were asked to present a short summary on the day, which was then followed by questions and a group discussion. At the end of each discussion, the panel deliberated on and provided a score for the respective outcomes.

The assessment panel were generally of the view that the organisation demonstrated ‘achieving activity’ for 3 of the 4 outcomes and ‘developing activity’ for 1 of the outcomes. When the scores for Domain 1 was tallied, the total came to 7.

Whilst not directly comparable to the previous year, this rating is not inconsistent with the overall position of the last assessment. It does however indicate the fact that more can be done to understand the differential impact on protected characteristic groups, both in the commissioned or provided services at NWAS.

ASSESSMENT OF DOMAINS 2 AND 3

Domains 2 and 3 were assessed by the trust in December 2024. A diverse panel was convened to review and score the evidence relating to workforce wellbeing and inclusive leadership.

The assessment panel were generally of the view that the organisation demonstrated ‘achieving activity’ for all of Domain 2 outcomes and ‘developing activity’ for all of Domain 3 outcomes. 

The scores awarded for the outcomes in Domain 3 by assessment panel this year were lower than the previous year. Attempts have been made to understand the reasons for this which may include:

• Greater scrutiny from the panel in respect of the evidence provided
• Quality and relevance of the evidence in relation to the Outcomes

The Trust Management Committee in reviewing the scores, queried the validity of the scoring given the variation with the previous assessment. However, the TMC approved the submission of the reporting template to NHSE based on current scoring, but with a view to looking at how the process can be improved for future assessments. One suggestion for improvement is that the evidence in Domain 3 be presented by a Board member, allowing for greater insight and real perspective on the role of the Board and Senior Leaders in respect of inclusive leadership. 

When the scores for each of the two Domains were tallied, the total came to 8 for Domain 2 and 3 for Domain 3 – a rating of 11 in total. This combined with the 7 for Domain 1 gave the Trust a score of 18 in total, and an overall organisational rating of ‘Developing’. 

ACTIONS & NEXT STEPS

In order to improve the quality and breadth of evidence for next year’s assessment, and more importantly, to ensure that the organisation has a comprehensive understanding of the diverse needs of staff and services user, a number of key objectives have been identified to support actions – see action plan and objectives at end of this report.

Name of Organisation
North West Ambulance Service NHS Trust

Organisation Board Sponsor/Lead
Lisa Ward KAM
Director of People

Name of Integrated Care System
Lancashire & South Cumbria ICB

1A: Patients (service users) have required levels of access to the service

Focus area: NWAS Public Health

The public health work has focused on understanding differences depending on deprivation, as the link between economic disadvantage and heath inequalities across protected characteristics, including gender, race or ethnicity, or disability.

Previous work includes:

• analysis to identify ‘hotspots’ of out-of-hospital cardiac arrest, 
• mapping availability of defibrillators, and 
• analysis of demand for 111 services based on deprivation.

This work has also helped to highlight the gap in patient’s ethnicity data in our 999 records and to drive initiatives towards improving completion.

One of the projects undertaken by the Public Health Team this year, is a project to support prevention and management of hypertension (persistent high blood pressure).Ther Trust has worked with a group of six GPs in Cheshire and Merseyside to test whether blood pressure data collected by ambulance crews could help identify patients with unknown hypertension. The target population included all adults 18 and over, this work is helping the Trust demonstrate the potential for ambulance services to contribute meaningfully to preventative care.

Another project undertaken this year in collaboration with the Business Information Team is the development of a Public Health dashboard. This consists of a series of reports to improve our understanding of the patient communities we serve. The reports will provide our activity data based on patient characteristics (age, sex, and ethnicity), and by population health data (location and deprivation index).This information will be visible to all the Trust and will help develop our understanding of different in access and outcomes by patient groups. This will also help us identify the services used by our CORE20 group, this is the population living in areas where the index of deprivation is in the highest 20%.

The Trust has developed training modules aimed for all staff and volunteers on two core Public Health topics: Health Inequalities and Make Every Contact Count. The aim of these modules is to develop an awareness of the wider causes of health inequalities, such as the places where we live and work and access to good education.

NWAS has committed to achieving the aims in our Trust Strategy in relation to improving health outcomes across our population, and our commitment to deliver positive value for the communities we serve, over and above delivery of our services. Supporting ambulance trust and wider sector to develop their capacity and capability to act on their role to reduce health inequalities, working effectively with our partners, including Integrated System and Board levels.

The Trust Long Term Workforce Plan, sets out a strategy to grow, retain and reform the workforce over the next 15 years. It will define the size, shape, mix and number of staff needed to deliver high quality patient care, now and into the future, including plans to increase the specialist public health workforce by 13% to deliver the best patient outcomes. 

The Top ‘5’ clinical priorities that require accelerated improvement; for adults are as follows: 

1. maternity
2. severe mental illness
3. chronic respiratory disease
4. early cancer diagnosis
5. cardiovascular disease prevention; for children and young people these are asthma, diabetes, epilepsy, oral health and mental health.

The Trust acknowledges inequalities and EDI topics are gaining prominence in the NHS. The Trust needs to start understanding the diversity in the population we serve as a first step to ensure we provide equal levels of service. Public Health work. The Trust  needs resources to engage with multiple partners and develop collaborations, with limited resources, and lack of required knowledge and skills means slow, limited progress.

Grading panel feedback

The grading panel asked if the model of public health is the same elsewhere in the ambulance sector, answer was that there is a small number who use the similar work on Public Health. The panel also asked a question around costs associated to public health work, response around incorporated into the work paramedics do, there is a cost to GPs to review the additional info, looking to reduce this cost and keep to a minimum and manageable and be absorbed by the GPs. Feedback from panel GP action to not spend at moment. Long term will be well received through value the work brings.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 1

Owner (Dept/Lead) : NWAS Public Health

1B: Individual patients (service users) health needs are met

Focus area: Improving cardiac arrest outcomes

The Trust has found that among resuscitated out-of-hospital cardiac arrest patients, discharge to survival is significantly lower in women compared with men. Published evidence shows unadjusted survival to discharge was lower among women compared with men (41% vs 50%).  When compared to white patients, international studies show non-white have lower rates of bystander CPR, lower rates of post arrest interventions and poorer outcomes.

Inequities in health systems classically has manifested as unequal distribution of clinical resources resulting in less timely access to care for marginalised communities. NWAS serves 928 middle layer super output areas (MSOA). MSOAs have an average population of 7200 people and vary in size depending on how densely populated an area is. Matching these areas with rates of cardiac arrest, defibrillator locations. Indices of deprivation and outcome data allowed a methodology to help determine areas of greatest need of targeted support when it comes to cardiac outcomes.

The following is a summary of work undertaken in last year to improve cardiac arrest and heart attack care::

• NWAS ensures electronic personal subscription available for all clinical staff, allowing access to July 2024 Clinical Considerations in Relation to Diversity and Equality Guidelines. This allows direct access to guidance relating to ethnicity and race, skin colour and tone, disability, maternity and gender related conditions, sexual orientation, cultural differences and related terminology.
• Local council partnerships producing aids to tackle language barriers (videos and leaflets to highlight importance of CPR/defibs in primary language)
• Pop up training and surveys in local faith and community centres
• “Train the trainers” initiatives with faith groups (e.g. Bolton Council of Mosques)
• In Cumbria, with “super ageing” population profile, focus on care home and assisted living warden given prevalence of CPR and changes associated with cognitive impairment
• “Red phone “ system introduced in every NW ED for time critical maternity transfers, recognising the health inequalities in both maternity outcomes and ethnic maternity populations
• All emergency ambulances have new child securing harnesses, ensuring all ages/weights of patients can be securely transferred in time critical manner, including cardiac arrests
• ‘Capacity to consent’ has been removed as criterion for access to percutaneous coronary intervention. This action advocates equitable access to specialist care for patients with conditions that impact capacity (i.e., severe autism, global learning needs, complex needs)
• New ECG criteria for heart attacks recognises  ECG variabilities between men and women and corrects for this gender inequality

Driver for delivering these outcomes are from a several key sources:

• NWAS Trust Strategy states ”The care we provide must be accessible to everyone and we will treat each person fairly based on their individual needs. We will take action to reduce inequalities in access, experience and health outcomes, especially for groups of patients considered vulnerable or at higher risk”
• NWAS internal Clinical Audit data incorporates EDI profiles

As part of Trust objectives, increased by-stander CPR is a key aim. Audit and survey identified barriers to this provision including:

• Gender – males have significantly increased odds of receiving bystander CPR compared to females
• Cultural and religious beliefs

Innovative strategies with volunteer partners, community group, faith group are required to prioritise CPR training access across certain occupational groups with significantly lower access.

Grading panel feedback

The panel questioned out of hospital arrest rate of 80% in the home and 12 to 13% in public place where is the rest of the % made up, the response was on ambulances, care homes and other places. Another question was asked around making inroads into large work places/factories, response was that community engagement team are currently doing this in the regions, making good headway, working with council partnerships and meetings being had with GM in the next few weeks around the priority sites and training requirements, working with companies like Amazon on their sites so they can be train the trainer so they can train their staff.

A point was made by panel about making inroads into the younger generation as this will impact long term. The response given was that the resus team come to community engagement teams along with positive action teams as an example at recruitment events.

Query from panel Troponin levels being checked in GM, how is this being measured around residual damage to heart as going straight to PCI rather than ED which would cause delay if went to ED. If Abnormal would go straight to specialist unit. Response is that this is a trial at the moment and looking at it’s effectiveness, historically changes in ECG would have gone to PCI, if chest pain this might not show on ECG so would go to ED. Troponin could show cardia incident, trial is currently ongoing but would not be right to discuss whilst results are ongoing.

Panel suggestion about holding community events, host in each county area, the response given was that the last three events have focussed on young people and also had demos at the events, to impact the community (small scale). Target groups focus this year has been Chinese community as example in Merseyside and resus team came and showed CPR training. Response around tailoring fears in the communities and adapting the training to the needs of those communities faith groups etc.

Comment CPADs in Rossendale are increasing.  As a Borough spread over a great area, we currently have 78 in the Valley, but more are needed and are encouraged and installed via community engagement and fund-raising. Response this work is ongoing with support from donations and community devices.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 2

Owner (Dept/Lead) : Medical Directorate

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

Focus area: Patient safety 

The Patient Safety Team continue to embed individualised approaches to ensuring that individuals with protected characteristics are free from harm when they use the service.

These insights have allowed the Trust to identify improvements relating to:

• Age 
• Disability (physical and learning disabilities)
• Gender
• Pregnancy and maternity 
• Other cultural elements that may make it challenging to engage with our service

The Patient Safety Team has successfully recruited three Patient Safety Partners (PSPs) from the Patient and Public Panel (PPP). These PSPs bring valuable patient safety insights through their lived experiences, particularly in relation to protected characteristics, examples include:

• Benchmarking via NARSF to understand how we can improve service for patients using language line during 999 calls
• Advanced Questionnaire Module in our Integrated Contact Centre which has decreased harm associated with delays for patients who have ingested high toxicity medications
• Significant work relating to improving pregnancy and maternity outcomes for patients

The Trust has developed the  Learning Disability and Autism Plan (2023-26) through extensive collaboration with stakeholders. It includes measures such as embedding Learning Disability and Autism Practitioners in mental health teams, enhancing workforce training, and adopting innovative communication tools.  The strategy also prioritises internal inclusivity by supporting neurodiverse staff and promoting awareness of hidden disabilities.

Alongside stories from patients, their families and our staff, which provide a human perspective, this ensures that safety improvements are informed not only by quantitative data but also by qualitative, empathetic narratives that highlight the lived experiences of those directly impacted. Insights from complaints, claims, and inquests serve as critical learning opportunities, helping us as an organisation to recognise systemic issues and address potential gaps in care.

Grading panel feedback

The panel raised the question that dementia is high number and they have a lot of challenges, will be looking at this in future? Response spoken with Mike Lloyd that it is on their radar for work in the future. Recognise with dementia patients previous deliver to ED, now recognise difficulties in doing this, examples of where dementia patients have then left, so its about safely leaving them at E.Ds. Panel stated they are working in Lancashire & South Cumbria around a partnership agreement to work on area of dementia. Response lots of work going with senior paramedics and hospital avoidance teams looking at doing what we can do to keep them safely out of hospital (virtual wards etc)

Panel question around volunteers can give feedback around patient safety, don’t have same access to Datix as don’t have NHS email, so cannot raise appropriate concerns via Datix but acknowledge management in this area are supportive, but should be a more robust system in place. Plus positive experiences not a method to share this which could be helpful to learnings. Response as a trust have looked at this over last 12 months, there is a significant cost for licenses for Microsoft to then get emails, this was gauged at around 100k, there is a DCIQ paper trail option which can follow and be submitted. Ongoing piece of work of how to input data into DCIQ when it’s offline and looking at a fit for purpose form. 

Response from panel: Responding to Kyle – The ‘mobility’ of CFRs i.e. some come and go quite quickly. It would be an onerous and expensive task to supply an email for each CFR who joins, some of whom experience, many do not stay for various reasons.  In 20+ years with Rossendale, I’ve lost count of the number who have trained and left. We have always been encouraged to report concerns to our CRDO.

Question what steps are you taking to ensure safety of wheelchair users, Response For information – we are looking at a new system within CRT which will have no significant cost overlay to what is proposed from MS licences.  At the point of implementation it will be reviewed with the DCIQ / patient experience teams to see how this can be integrated 

Feedback from panel: I appreciate the feedback, but I as mentioned from my prospective the needs to be a more digital way that is equal to those who are paid in terms of reporting processes. I am just highlighting an observation in terms of funding that seems to be the barrier as to why no access to systems that can help provide feedback and in a safe forum.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 2

Owner (Dept/Lead) : Patient Safety Team

1D: Patients (service users) report positive experiences of the service

Focus areas: Friends and Family Test and work undertaken by the Patient Public Panel (PPP) Team.

The Friends and Family Test (FFT) had 5.3% BME PES survey respondents, and 87.50% ‘strongly agree/agreed’ that they were treated with dignity, compassion and respect, with 87.50% also rating their overall satisfaction of the service as ‘very good/good’. For 6.8% of BME FFT respondents, we see a rating of 90.72% for their ‘overall satisfaction of the service’.

Where patients have indicated an impairment, (31.25% of BME survey respondents), this group gave a rating of 80% for being treated with ‘dignity, compassion and respect’, with a similar score for their overall satisfaction of the service. In relation to FFT respondents, 53.61% of BME respondents indicated that they had an impairment. Here the group gave a rating of 92.31% for their overall satisfaction of the service.

Through annual mapping of groups and priority for engagement, 2024/25 includes a focus on Chinese and Jewish communities (which have previously been under represented). This has will be through the following:

• Patient Public and Community Engagement Framework together with the trust’s Equality Diversity and Inclusion priorities
• Patient demographic stats
• Patient experience collated via all our surveys and engagement approaches e.g. Friends and Family Test (FFT) surveys, engagement with specialist and cultural patient groups
• Working with trust staff networks; Race Equality, Disability, Women’s, Faith Religion and Culture etc
• Learning from trust wide Community Listening Events – annually, one per each County area

The Trust acknowledged a lack of accurate recording of service user ethnicity on patient experience surveys. This is due to the following factors:

 . 

• NHS guidance states that patients do not have to disclose their demographic data. 
• Patient demographic data is not available to the trust via the NHS Spine. 
• We are unable to capture demographic data via 999 calls. 
• Inconsistent recording of patient demographic data by emergency crews on scene

The team have recruited a new post – Patient Inclusion Manager role to assist in identifying barriers to disclosure and potential positive solutions. The Trust has also worked with a cohort of University of Liverpool Public Health Masters’ Students who are currently working on dissertation project  ‘Approaches to Increased Disclosure of Ethnicity Data on Patient Feedback Surveys’.

Grading panel feedback

A question from the panel asked about how this is fed into service lines, Response is that individual reports are done for service lines, also report high level findings to the board on quarterly basis, go to D&I sub group, and this group closely examine the demographic element is the same experience as of those without. Do also summaries of events with recommendations for improvements and shared with groups who attend, also have own annual report and contribute to others

Reflection from panel around appreciation of the PPP team working with public and community groups

Rating: 2

Owner (Dept/Lead) : Patient Experience Team

Domain 1: Commissioned or provided services overall rating: 7

Domain 2: Workforce health and well-being

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

Focus area: Occupational Health services.

The team through the new occupational health (OH) provided has looked at the MI data availability around age and sex – and can now see a greater level of MI data with insight into age and gender but are still limited to the characteristics data gathered by Occupational Health and their MI data does not expand currently beyond age and gender

All interactions with our OH provider come with a feedback request following treatment to allow the team to identify issues that may arise with any specific individual of (protected) characteristic group. 

Recent analysis has raised from a male/female perspective that there is a marked higher uptake of mental health support. This is being reviewed with consideration of a project working with a university to launch a BALM trial to targeted male populations within our workforce.

Obesity: The Trust’s wellbeing offer provides signposting to a range of information and services relating to obesity i.e. fitness, heart health and healthy eating. The OH service also provides advice and guidance to staff in relation with obesity. 

Diabetes: Staff who are diabetic are provided with access to storage facilities for medication and can take time to take/administer medication and attend medical appointments. Support and advice is also provided on healthier lifestyle changes to help begin to reverse or ward off the possibility of type 2 diabetes due to diet.

Support to manage Asthma/COPD: Staff with asthma and COPD conditions are supported with access to OH services, time to attend medical appointments and through the wellbeing offer. In high risk environments with exposure such as workshops and HART, annual health surveillance is undertaken.

Support for mental health conditions: We recognise that mental health is our biggest absence driver. It is noted to date (April to September) that 566 mental health referrals have been made, many of these leading to low intensity CBT counselling and a large volume of complex counselling services (EMDR/hi intensity CBT) have been authorised. The provision has also increased support to 6 sessions in 12 months per employee. Specific support and counselling has been provided with some individuals newly diagnosed with neurodivergent conditions such as autism and ADHD. 

Grading panel feedback

The grading panel noted the value of how chaplaincy supports senior staff in relation to mental health and related issues. There was discussion from the panel around how staff may not be just off/classified as with mental health, but diagnosis could be other related/linked. A point was raised from the panel around senior staff not being aware of the ability to create management referrals. The panel questioned the depth of protected characteristic data available from the new occupational health provider,  current missed opportunity with age and gender being only data so far from Optima. It was also asked from the panel if the new OH provider portal could be checked to meet compliance with Web Accessibility Guidance (WAG)  And even though improvement in provision is clear it was noted that visibility to staff could be improved. A concern raised by the panel was with the new provider physio referrals which used to take hours to hear back are now taking weeks, causing longer delays supporting the return of staff to work.

A positive note from the panel was that info around diabetes was difficult to obtain in the past, the panel has seen a notable improvement in guidance available. It was also noted that the trust has moved from the past when having diabetes would have stopped careers in the service. It was noted from the panel that there is a lack of understanding from front line staff that there the Wellbeing Hub/pages exist. 

A point was made that the wellbeing passport are being used, this could be promoted more, and an opportunity could be SP inductions in January 2025. A point of note was asked around utilisation of the workforce wellbeing officers to meet the bespoke needs of each region. 

The panel questioned how the cost for Neurodiversity referrals is attributed/obtained. 

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 2

Owner (Dept/Lead) : HR Business Partnering

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

Focus areas: Violence Prevention and Reduction, HR Business Partnering, and Sexual Safety Steering Group. 

The Staff Survey 2023 results tell us that over 98% of staff indicated they had not experienced physical violence from managers of colleagues, but more than 1 in 10 said they had experienced harassment, bullying or abuse in work. 

Also, for the first time in 2023, the Survey asked about unwanted sexual behaviour – the results show that around 8% have experienced unwanted behaviour of a sexual nature from colleagues. This rises to more than 1 in 10 staff in PES and is higher for female and LGBT+ staff. 

Disabled staff are more likely to experience abuse in some form from the public, compared to non-disabled staff. 

Around 1 in 5 disabled staff have experienced some type of abuse from colleagues, but the likelihood of non-disabled having these negatives experiences is 1 in 10. 

BME staff and male staff are considerably less likely to report their negative experiences, as only a third indicated that they did so compared to nearly

HRBP

Sexual Safety (SS) in the workplace, followed on from the work of the SS Steering group which commenced in August 2023. In April we launched our SS toolkit and in May 2024 the Trust launched its sexual safety campaign – ‘Stop, speak, support’, followed by a series of roadshows touring emergency departments and stations to talk to staff about our the SS initiative and highlight the collective responsibility of all staff to make NWAS a safe place to work.

1. In August 2024 we launched by stander guidance to sit alongside the SS Toolkit,

Suicide prevention, In May 2024 we officially launch the action cards for dealing with Significant illness, injury, suicide attempt, suicide or death in service. 

In September 2024 – updates were made to the Datix system to enable the trust to report and record at a central point staff incidents involving Significant Self Harm / Suicide Attempt / Suspected Suicide. 

Violence Prevention and Reduction Team (VPR)

The Trust has recruited a team dedicated to Violence and Aggression that will also focus on the impacts that V&A has on those in groups of protected characteristics. There has been an improvement in data accuracy to understand the impact of Violence and Aggression of Protected characteristics groups. Reporting now allows staff to report on any incident and if they felt a protected characteristic was an aggravating factor to the incident.

VPR team sits on network groups to discuss initiatives and incidents that have impacted those with protected characteristics. Networks are given the opportunity to voice to VPR team how they would like to be supported and are offered involvement in initiatives. This empowers staff to be part of the process and makes initiatives valued across the trust.

Grading panel feedback

The panel questioned if the noted drop in VPR incidents was attributed to incidents such as Southport. The panel asked if anonymised case/topline information showing overall actions/outcomes/themes could be reported so trust could be further built to encourage reporting. A positive noted was that in the last 12 months the work that has been put into bullying, harassment and sexual safety has been immense, and acknowledging that VPR lead Natalie and team have accomplished and real positivity around the trust to make a safe environment for all. The panel noted that it is not necessarily new staff who require civility training.

A positive note from the panel is seeing an uplift in those declaring their protected characteristic. It was noted that there continues to be apathy with derogatory language with regards disability. It was also noted that it is difficult to look at characteristics in isolation as you can be a Woman with a disability as an example.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 2

Owner (Dept/Lead) : HR Business Partnering, Sexual Safety Steering Group, Violence Prevention Reduction and Security Team

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

Focus areas: Chaplain for Staff Wellbeing and Freedom To Speak Up 

The Chaplain for Staff Wellbeing, Reverend Karen provides a confidential listening and support service in times of change, challenge, and distress. Engagement with the chaplaincy service provides the opportunity to explore issues of faith and spirituality and how they impact both personally and in the workplace.

The Chaplain offers pastoral care to people of all faiths and none, and regardless of background, or any protected characteristic group

The chaplain has attended the Women’s Network and Racial Equality day which focused on maternal health and pregnancy. There is active links with the Race Equality Network And has provided 1-1 and group pastoral support for staff who have experienced anxiety and verbal aggression due to heightened societal ,racial, tensions. Staff have sought 1-1 pastoral support sessions to discuss the implications of their disabilities and how to manage some discrimination that they have experienced as a result. The chaplain has been recognised as an ally by many within the LGBT+ community within the organisation. Pastoral support was delivered by the chaplain at the Women’s Network event that focused on sexual safety. also attended the Sexual Safety Road Show events

Freedom to Speak Up (F2SU)

The F2SU Team have some ability to track the percentage of our concerns where reporters wish to record a protected characteristic. Currently this is done by disability, ethnicity, gender and sexual orientation. We compare the percentage of concerns where reporters highlight a protected characteristic, against wider trust level workforce data to see if we have comparable rates of reports coming from our diverse range of staff.

Work has continued to try and make speaking up easy for people and have a range of accessible methods available to in order for staff to speak up, tailoring the offer to ensure that whatever the preferred method is, some form of option is available to them. This includes email, text, phone, written post, online form, social media

FTSU guardians have been working with key internal and external stakeholders to ensure that speaking up is being normalised within the organisation, and to give a clear message that speaking up is a positive thing and not to be seen with any negative connotation. This has included speaking at trust inductions, service line SMT meetings, student inductions, and staff forums across the trust.

The F2SU Team have seen lower rates of staff with protected characteristics speaking up to FTSU than the trust rates against the workforce data. This needs to be further investigated before conclusions are made. We need to establish if this is replicated across other methods of speaking up such as DATIX, or formal HR processes and the reasons for that.

The panel raised the point around how far can anonymity be kept when looking into/investigating an issue and levels of reporting.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 2

Owner (Dept/lead): Chaplain for Staff Wellbeing, Freedom to Speak Up

2D: Staff recommend the organisation as a place to work and receive treatment

Focus areas: NHS Staff Survey results and Exit Interviews data

ED&I Team

The following information is taken from the National Staff Survey (NSS) through the Trust Staff Engagement Team and is broken down by the following available protected characteristic groups:

Disability: Just under half of staff who have a disability said they would recommend NWAS as a place to work compared to 56% of non-disabled staff., and 6 in 10 Disabled staff would recommend the standard of care provided by NWAS, compared to 7 in 10 non-disabled staff.

Age: The 16-20 & 21-30 & 66+ age groups were more likely to recommend NWAS as a place to work, and over 70% of 16-20 and 66+ staff would recommend the standard of care provided by NWAS.

Gender: Female staff responded more positively that they would recommend NWAS as a place to work compared to male colleagues (difference +5.8%). However, only 3 in 10 staff who prefer to self-describe their gender state they would recommend, and more than 70% of female staff would recommend the standard of care provided by NWAS compared to 66% of male staff.

Ethnicity: BME staff were likely to recommend NWAS as a place to work compared to white colleagues, and almost 7 in 10 of both White and BME staff would recommend the standard of care provided by NWAS.

Religion: 7 in 10 staff who stated their religion is Hinduism said they would recommend NWAS as a place to work, followed Christian staff (nearly 60%), and at least 60% of respondents in all faith groups (including no faith) said happy with the standard of care provided by NWAS.

Sexuality: Nearly 60% of LGBT+ staff would recommend NWAS as a place to work, compared to Heterosexual/Straight staff at 54.9%, and 6 in 10 LGBT+ staff would recommend the standard of care provided by NWAS, compared to 7 in 10 Heterosexual/Straight staff.

HR Corporate

The work around exit interviews moved onto Microsoft Forms in June 2024, improving its accessibility via screen reader functionality, high colour contrast and keyboard navigation.

Responses from the exit interviews indicate that 67% of respondents would work for NWAS again in the future, with 62% of staff feeling valued by the organisation. Based on equalities monitoring data collected from exit interviews for the period of June to September 2024, there are no demographics with disproportionate responses to whether they would work for NWAS again in the future. An example of this is the ‘disability’ response at 70% compared to the ‘no disability’ response at 68%

The NSS website supports staff with accessibility needs and is accessible via speech recognition software, keyboard navigation, and also the ability to change contrast levels and up to 500% zoom.

In 2022, 46.4% of staff stated they would recommend NWAS as a place to work (q25c) This increased to 54% in 2023. Moreover, where in 2022 60.8% of staff said they would be happy with the standard of care provided by NWAS if a friend or relative needed treatment (q25d). This increased to 67.5% in 2023. Demographic responses were broadly similar for both q25c and q25d. For example, the ‘female’ response to q25c was 57.5% and the ‘male’ response was 51.7%.Further data on other protected characteristics is available in the full grading pack info.

Two new questions introduced in the 2023 survey were q17a ‘not experienced unwanted behaviour of a sexual nature from other colleagues’ (79.6%) and q17b ‘not experienced unwanted behaviour of a sexual nature from other colleagues’ (92.2%). The responses to these questions from female staff were lower than the overall response: q17a was 75.2% and q17b was 90.5%.

A positive to note was that moving from the old exit interview form to having an interview/meeting gave staff the feeling of being engaged. A panel member stated when the reasons for leaving are known that there doesn’t appear to be anything done about it. A point raised by the panel around exit interview data and could this be for when staff leave to go to a different internal role to identify any underlying themes/hotspot areas, a panel member did advise they had gone through this an perhaps this was to do with consistency of approach. Also if a member of staff is leaving to an external role at point of notification or even sooner when the staff member is thinking is there the option as other organisations have ‘stay’ interviews. 

An observation from the panel was that leadership can tend to stick to a narrative of why staff move sectors, whilst not considering based on where the staff already lives as geographic spread of the trust is a major factor. Another observation is that staff potentially do not feel they have opportunities to be open around barriers and/or flexibility. Salary and how the trust is bound by agenda for change (AfC), the point was raised that AfC is not tracking above the living wage/minimum wage.

The panel noted that with the service model delivery review, new opportunities have been created such as Aps etc.

The panel observed that the data shown was predominantly the experience of straight white men.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 2

Dept: HR Corporate

Domain 2: Workforce health and well-being overall rating: 8

Domain 3: Inclusive leadership

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

The Trust refreshed EDI priorities 2024-2026 were approved by the Board of Directors in July 2024:

Priority 1: We will embed fair and inclusive recruitment and progression processes to improve the diversity of the workforce at all levels.

Priority 2: We will educate and empower our workforce and leaders to promote a positive psychologically safe culture, to support a reduction in the experience of bullying, harassment, discrimination and an improvement in retention.

Priority 3: We will reduce health inequalities for our patients.

The refresh was also accompanied by the EDI Annual Plan 2024/25 developed to monitor progress against the actions within the three areas which identifies the focus of the improvement goals, how they will be delivered and the measures of success for each priority.

All Board members, system leaders and staff with line management responsibilities continue to support a large number of events and programmes to promote and raise awareness of relating to equality and health inequalities.

Directors continue in their Executive Champion roles aligned with networks or particular equality strands. Champions are accountable for supporting network objectives, acting as allies and advocates and for bringing the perspective of their equality strands to decision making.

The Trust governance structure includes the Diversity and Inclusion Group provides assurance that the Trust maintains a strategic overview of the Trust’s activities in the area of diversity and inclusion, aligned to either the People Strategy, Quality Strategy or the National People Plan, which helps to guide, steer and challenge progress in the delivery of the Trust’s EDI strategic priorities and objectives.

The Board has and continues to aim to lead from the front to support the work undertaken to progress the equality, diversity and inclusion agenda. The Board aim to keep the conversation fresh with continuous education relating to these topics.

The Board through the Committee assurance structure will continue to receive assurance and annual reports, with further opportunity to become further involved to support developments.

The Chairman is the Non-Executive champion for equality, diversity and inclusion and will continue to drive this agenda forward.

Objectives relating to equality and diversity are implemented into the objectives of senior managers to provide visible leadership around the diversity and inclusion agenda. This continues at Board level who are leading from the front in order to promote equality and equity across the organisation. Board members are also required to comply with the NHS Leadership Competency Framework for Board members to promote equality and inclusion, reducing health and workforce inequalities and completes a self-assessment

Health Inequalities – Mental Health: The new mental health response vehicle model went live in April 2024 and has been developed in conjunction with mental health trusts and the ICB, alongside the NHS Long Term Plan and supports patients by reducing unnecessary conveyance to ED and signposting to more appropriate pathways of care

EDI: Achieved Gold standard for the third consecutive year in the Employers Network for Equality & Inclusion (ENEI) Talent, Inclusion & Diversity Evaluation (TIDE) accreditation. Third highest out of 185 global entries – measures EDI intentions and performance against other organisation and a range of sectors.

Equality Impact Assessments – carried-out at the same time as the review of an existing or proposal service, policy or activity and should be carried out at the beginning of the decision making process to properly engage with diverse groups and in order to comply with the Public Sector Equality duty.

Race: First ever Iftar dinner held on 27 March 2024 to commemorate the holy month of Ramadan

Black History Month & World Menopause day – 18 October – a join event to raise awareness, particularly the experiences of ethnic minority women

Sex: Introduction of a Menopause Policy & Procedure and introduced Menopause Champions and start of Menopause Natter Cafes for staff

Disability: Disability/Race Equality network Event – World Sight Day 10th October, a virtual event for eye health

Creation of a Learning disability & autism Plan 2023 – 2026, guided by people with learning disabilities and/or autistic people, families, careers, health and care professional and third sector partners such as local learning disability network and the national autistic society.

Age: World Elder Abuse Awareness Day 15/6/24 – theme ’spotlight on Older Persons in Emergencies’.

Gender: Policy on supporting Trans, non-binary, Gender Fluid and Non-Cisgender staff updated and republished October 24.

All staff have the option to display their pronoun in email signatures and on ID badges

Religion – Religion, Culture & Believe Forum July 24

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 1

Dept: Corporate Affairs Directorate / Head of Corporate Governance

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

A key focus of the reporting processes are to recognise that Equality related impacts are key to the Board of Directors, Committees and Groups. Specifically, reports/proposals are expected to highlight whether any specific staff or patient groups would be impacted by any decision made by the Board and where possible how this can be mitigated.

The completion of an Equality Impact Assessment (EIA) is an evidence-based approach, designed to help the Trust ensure that policies, practices, events and decision-making processes are fair and do not present barriers to participation or disadvantage any groups, with protected characteristics, from participating. The EIA process assesses the impact to these group compared to those not from the 9 protected characteristics and other linked/similar groups. This is an essential element of the Boards decision making and demonstrates compliance with the Public Sector Equality Duty. The Corporate Governance Team support this work through the use of report templates and ensuring policy authors have engaged with the Inclusion Team in relation to completing an EIA to accompany policies and strategies.

Risks are discussed: both the broader aspects of approaches and the impact on individual groups. This section of the report is a key focus for the Board and authors consider the equality related impacts. Some more comprehensively than others and seems to be improving. This again is as a result of the focus on equality and health inequalities being undertaken by the Trust. Board papers can be viewed on the Trust website to identify this www.nwas.nhs.uk

The Board receives information about the staff survey and information about the responses of different staff groups. Directorates are requested to submit their local people plan in response to the results of the staff survey.

The Resources Committee also receive an overview of workforce data that the Trust is required to publish in relation to WRES, WDES and Gender Pay Gap. This report details the actions in places to address inequalities in the workplace and areas of focus

The Diversity & Inclusion (D&I) Group receives the EDI risk register providing the Group with an opportunity to discuss, identify the controls/gaps that require further assurance to mitigate these risks i.e. mental health/patients with disabilities.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 1

Dept: Corporate Affairs Directorate / Head of Corporate Governance

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

There are a number of mechanisms for the Board to manage performance and monitor progress as follows:

• July 2024: the Board received assurance through the Annual Equality, Diversity and Inclusion Annual Report 2023/24. The report shows progress and updates on the EDI priorities, around attraction, recruitment and progression, developing a culturally competent organisation and addresses health inequalities. It also provides an overview of the statutory regulatory data reporting including WRES, WDES, delivery of community and patient engagement and the work of the Staff Networks who make a positive contribution to the culture of the organisation.
• April 2024:Board received presentation relating to the culture review.
• July 2024: the Board received the EDI Priorities 2024-2026 and EDI Annual Plan.
• May 2024: Resources Committee received the Culture Review providing a background to the publication of the Culture Review of ambulance services in February 2024.
• July 2024: Regulatory and Statutory EDI Workforce Report for 2023/24.

Reporting: 

• Workforce Race Equality Standard (WRES)
• Workforce Disability Equality Standard (/WDES) Data
• Gender Pay Gap.(GPG)
• Workforce Equality Data Monitoring

The Diversity and Inclusion Group provides assurance to Trust Management Committee on progress of its work through Reports. The work programme for the Group identifies when assurance against the three EDI priorities are scheduled during 2024/25.

The Workforce Indicator Report to Resources Committee provides bi-monthly assurance against sickness levels; mandatory training and performance against targets; appraisal completion rates against targets, turnover; vacancy position; casework; disciplinaries. Assurance is provided to the Board via the Resources Committee Chairs Assurance Report.

Bi-monthly Integrated performance Reports are provided to the Board. This report provides bi-monthly data to the Board in relation to a set of metrics required by the Single Oversight Framework relating quality, effectiveness, operational performance, finance and workforce data. A review of the data against protected characteristics to understand and improve patient experience is undertaken by the Diversity and Inclusion Group.

For further information, please see 2024/25 NWAS EDS evidence pack

Rating: 1

Dept: Corporate Affairs Directorate / Head of Corporate Governance

Domain 3: Inclusive leadership overall rating: 3

EDS Organisation Rating (overall rating): 18, Developing

Domain 1: Commissioned or provided services

Domain 2: Workforce health and well-being

Domain 3: Inclusive leadership

Staff Experience (ED&I) Team

North West Ambulance Service NHS Trust[email protected]