Equality Outcomes & Mainstreaming Progress Report 2017-19€¦ · Web viewEquality Outcomes & Mainstreaming Progress Report 2017-19. If you would like this document in alternative

Equality Outcomes & Mainstreaming Progress Report 2017-19

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Published 04 April 2019

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CONTENTS PAGESection 1: Equality Outcomes & Mainstreaming Report 4

1.1Introduction 41.2Legislative background and current legislative requirements

- Public Sector General Equality Duty- Public Sector Specific Duties- Fairer Scotland Duty- Health and Social Integration

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Section 2: Mainstreaming Progress Report 2017-19 72.1Background 72.2PEOPLE

- Mandatory equalities training- Staff development: Equal Opportunities & diversity- Flexible working practices- Supporting carers in the workplace- Highland Compassionate Communities

8889910

2.3QUALITY- Language Interpretation and Communication Support- A Right to Speak – Augmentative and Alternative Communication- Access Support Cards- Stonewall Champion

1010111213

2.4CARE- Near Me- Development of Screening Awareness Community Champions and Volunteer

Programme

131313

2.5PARTICIPATION AND EMPOWERMENT- Awareness raising and events- Volunteer Breastfeeding Peer Supporters- Infant Feeding Support Workers- Highland Green Health Partnership- Hate Free Highland- Gender based violence policy- Working with partners- Suicide Prevention App

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2.6EMBEDDING EQUALITY WITHIN BUSINESS FUNCTIONS- Procurement strategy

1919

2.7Conclusion and Potential Next Steps- Equality & Diversity Champions- Review of the EQIA process

192020

Section 3: Equality Outcomes Progress Report 21 3.1 Background 21

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ANNEX 1 – Equality Outcomes Action Plan 22Equality Outcome1 – Increase diversity in leadership and workforce participation 22Equality Outcome 2 – Identified groups have improved experiences of accessing services and information

28

Equality Outcome 3 – Identified groups of children and young people will benefit from improved access to mental health services and support

32

Equality Outcome 4 – People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them

33

Equality Outcome 5 – In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it

35

Equality Outcome 6 – Community Planning Partnerships will work towards addressing socio-economic disadvantage as set out on the Local Outcome Improvement Plans

37

Section 4: Workforce data 39ANNEX 2 – Employee data and information 39ANNEX 3 – Gender pay gap statement 55

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Section 1: Equality Outcomes & Mainstreaming Report

1.1 Introduction

The purpose of this report is to describe progress made in the period 2017-2019 towards NHS Highland’s equality and diversity outcomes, identify areas for further development and how we aim to continue to embed equality, diversity and person-centred care throughout NHS Highland.

Following on from the introduction of the Equality Act 2010 NHS Highland published its first set of equality outcomes in 2013 which covered the four year period until 2017. In 2015 progress report was published which included a recommendation that a review was undertaken to assess whether the outcomes previously identified were relevant, in line with the Board priorities and to ensure that they were evidence-based, measureable and achievable. The review was completed in April 2016. The Equality Outcomes and Mainstreaming Report for 2017-2021 incorporated the recommendations contained in the review and, following consultation with stakeholders within and out with the organisation, new outcomes were developed with a focus on the following themes:-

Developing an evidence base and improving data collection Celebrating difference within our workforce Person centred care

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1.2 Legislative background and current legislative requirements

Public Sector General Equality Duty

The Public Sector Equality Duty, laid out in the Equality Act 2010 (the Act), came into force in Scotland in April 2011. This equality duty is often referred to as the “general duty” and it requires public authorities to have “due regard” to the need to:

Eliminate unlawful discrimination, harassment and victimisation and other conduct that is prohibited by the Act.

Advance equality of opportunity between people who share a relevant protected characteristic and those who do not.

Foster good relations between people who share a protected characteristic and those who do not.

The general duty was developed to harmonise existing equalities duties under various pieces of legislation and to extend it across all protected characteristic:

The purpose of the general duty is to make public bodies, including health boards, mainstream equality into their day to day business by proactively advancing equality, encouraging good community relations and addressing discrimination.

It is not the job of one person within an organisation but the responsibility of all to consider how positive contributions can be made to remove discriminatory barriers. Essentially, it is an organisational responsibility and leadership and staff awareness is fundamental to success.

Public Sector Specific Duties

The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 (the Regulations) also impose “specific duties” on Scottish public authorities to publish a set of Equality Outcomes at 4 yearly intervals and thereafter to report on progress every 2 years. The specific duties are to:-

report progress made on mainstreaming the equality duty publish equality outcomes and report progress assess and review policies and practices (impact assessments) gather and use employee information publish statements on equal pay consider award criteria and conditions in relation to public procurement publish in a manner which is accessible

The purpose of the specific duties in Scotland is to help those public authorities in their performance of the general equality duty. The specific duties provide a framework to drive long term, measurable improvement in the mainstreaming of equality across public services.

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Fairer Scotland Duty

From April 2018 the Fairer Scotland Duty, under Part 1 of the Equality Act 2010, came into force across Scotland. The new duty places a legal responsibility on public bodies, including Health Boards to ‘pay due regard’ to how they can reduce inequalities of outcome caused by socio-economic disadvantage when making strategic decisions. Public bodies will also be required to publish written assessments showing how they have fulfilled the duty.

NHS Highland has therefore been focusing on how to implement the Fairer Scotland Duty and align this with the existing duties under the 2010 Act and other commitments.

NHS Highland has taken significant steps to mainstream equality and manage diversity within our NHS services for patients, carers, public, staff and our local communities. However, we are realistic in our approach that fully mainstreaming equality remains a challenge. NHS Highland is committed to ensuring that equality is embedded into our work, that we provide the information that is required to be published and that the equalities agenda continues to be an area of ongoing improvement and development for NHS Highland.

Health and Social Integration

The Public Bodies (Joint Working) (Scotland) Act 2014 came into force in April 2014 resulting in the integration of health and social care. This brought significant changes to the way services are delivered and aims to help bring long-term sustainability to services and improve the health and wellbeing of the people of Scotland. Greater emphasis is placed on supporting people in their own homes and communities and reducing inappropriate hospital and care home use.

Across Scotland local authorities and NHS Boards created formal partnership arrangements (Integration Authorities) to integrate the planning, management and delivery of adult health and social care services (including some hospital services). These arrangements are either in the form of a body corporate model (known as an Integrated Joint Board) or a lead agency model.

In April 2012, Highland Health and Social Care Partnership (Highland HSCP) adopted the lead agency model. Under this model NHS Highland assume responsibility for adult health and social care and Highland Council assume responsibility for children’s care and services.

Along with all other HSCPs, Argyll & Bute HSCP adopted the Integrated Joint Board (IJB) model in 2015. Under this model Argyll & Bute IJB is responsible for children’s health and social care services, criminal justice social work and all acute services.

Argyll & Bute Health and Social Care Partnership Integrated Joint Board published their Mainstream Report and Equalities Outcome Framework 2016-2020. A Progress Report covering 2016-18 has been prepared and published.

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Section 2: Mainstreaming Progress Report 2017-19

2.1 Background

Mainstreaming equality means integrating equalities into day to day business of a public body. As a public body, NHS Highland needs to consider the impact of our actions on all our service users, particularly those who share a protected characteristic(s). Taking equalities into account in the way we operate should be part of everything we do.

Mainstreaming equality leads to improved quality of service design and delivery for example: equitable access and equity of informed, person-centred care that can cope with the diverse needs of the Highland population. This leads to improved outcomes for our patients, the people we support as well as improved working environments for staff. This is a long term process, inherently linked to organisational development and culture change.

We continuously build on our commitment to community engagement and participation, creative learning, equalities diversity and inclusion to address the increasing health inequalities that affect local people. We do this by:

Bringing services together and improving pathways Ensuring services in the community are accessible to all Giving people more choice and control Helping people to live as independently as possible Tackling inequalities and building strong communities Focusing on prevention and early intervention Providing effective support for carers Listening to patients and using service users’ feedback to improve services

The Board plays a lead role in promoting the ethos of working collectively and efficiently to ensure that equality is considered as a key component across all our functions. This involves a range of senior management and staff to ensure that a common and consistent approach is taken to integrate equality into policies and procedures across all services.

Mainstreaming is not an overnight process of change. Progress may appear slow, yet it is recognised that it takes time to build the knowledge and skills of managers and staff to put this into practice. Below we have outlined some snapshot examples of how we are and will continue to actively mainstream and improve our work in equalities within the organisation. There are of course areas that require further development in order to ensure that NHS Highland continues to move towards full compliance with the duties set out in the Equality Act.

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2.2 People

Mandatory equalities trainingAs part of induction to NHS Highland, all new members of staff are required to complete statutory and mandatory training courses. One of these courses is the Highland: Equality and Human Rights module which aims to raise awareness about the importance of equality, diversity and human rights, provides a brief overview of equality legislation and encourages staff to consider, reflect and challenge their own perceptions and practice.

All staff (including Senior Managers and Board members) are required to refresh this core training every three years. The purpose of the refresher course is to ensure that all staff continue to be aware of equality and diversity and of NHS Highland’s duty to eliminate discrimination and promote equality across all services.

Our current compliance rate at 28 February 2019 is 72%. In 2018 a Training Compliance Officer has been recruited to identify new employees to strengthen compliance.

We also have a further development in that a learnPro Course Booking System (CBS) has been implemented which enables line managers to create an online training plan for employees.

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Equality and Diversity

Staff development: Equal Opportunities & Diversity NHS Highland and The Highland Council have worked in partnership to develop and deliver a new equality and diversity learning opportunity. This training is available to both NHS and council employees. This partnership approach not only shares resources of both organisations but aims to have a consistent approach to equalities training across Highland. This training is delivered in a group setting and gives an overview of the equality legislation, case studies and examples of good practice. The training also includes group discussion exercises which encourage participants to question their own biases, stereotypes and preconceptions of equality groups and issues. Since 2017 almost 100 people have completed this course.

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As well as face to face training we are also keen to explore training opportunities that reduce the need for staff travel, for example, by webinars or video conferencing.

Flexible Working Practices NHS Highland recognises that the workforce is now more diverse than ever before, reflecting changes in society. Flexible opportunities benefit everyone: employers, employees and their families. It makes sound business sense to be open to flexible working requests from employees as accommodating requests can help:- retain skilled staff and reduce recruitment costs; decrease absenteeism; be part of good employment practice as flexible options support the delivery of improved service outcomes providing benefits for the organisations, individuals and patients. A suite of work life policies1 have been introduced to provide flexible working practices.

Supporting carers in the workplaceThe 2011 census illustrated that 7% of the Highland population were unpaid carers and it is anticipated that the number of carers will increase as the population ages. NHS Highland recognises the valuable contribution of carers in the community but also staff members who have additional responsibilities of caring.

NHS Highland identified the Carer Positive initiative as an opportunity to seek accreditation for the existing support provided to carers within our workforce, and also as a means

of focusing what we could do to improve, and to raise awareness of this issue.

Carer Positive is a Scottish Government funded initiative which recognises employers who are aware and supportive of unpaid carers in the workplace. The award is given out based on five main criteria including:-

- how carers are enabled to identify themselves- what policies, employee assistance and peer support mechanisms are in place- the way this information is communicated to the workforce

Carers can experience high levels of stress when balancing work with caring responsibilities and this can result in feeling unable to sustain employment or progress in their career. By promoting the support available to carers and raising awareness among line managers, NHS Highland’s commitment to Carer Positive seeks to support the wellbeing and mental health of the workforce, to enable carers to continue in employment and to access training and development opportunities.

Whilst research suggests that caring responsibilities are disproportionately taken on by women, and our work in this area is likely to have a positive impact on gender equality, we actively seek to support both female and male carers.

We achieved the Engaged level of the Carer Positive award in 2016 and have maintained this by evidencing that the organisation has awareness of carers and has made a commitment to support carers through workplace polices/working practices and that systems and processes have been developed to support this.

1 Support for carers and young carers, Childcare (inc childcare vouchers), Home working, Part time working, Flexible working and Job Share

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Highland Compassionate CommunitiesLed by Public Health, NHS Highland has developed a partnership with Dementia Friendly Communities Ltd to roll out the dementia friendly community Circle of Support model that was initially developed in Helmsdale. Supported by some funding from Life Changes Trust, this programme of work aims to work with communities to develop community led support and services for some of the most vulnerable people in our rural communities including people affected by dementia, but also a number of other groups – such as those with life limiting illness, long term conditions, individuals who are lonely and carers who can benefit from a network of support in their local community.

Highland Compassionate Communities recognises that while many rural communities across the Highlands face similar challenges, no two communities are the same. Using lessons learned from the Helmsdale model, the initiative has been set up with the aim of developing community led activity and services based on local need that will see a network of local support that is designed to assist vulnerable people to lead a life of quality within their own homes and communities for as long as possible. Further trial projects are talking place in Appin, Argyll and Milton in Ross-shire.

2.3 Quality

Language Interpretation and Communication Support

NHS Highland wants to ensure equitable access and communication difficulties can be a barrier for people whose first language is not English or for people who require communication support2.

NHS Highland commissions the following:-

Face to face interpretation of foreign language

Telephone interpretation of foreign language

Communication support – British Sign Language/English interpreters, lip speakers, note takers

2 For example: People who are Deaf, hard of hearing, blind or Deafblind

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From April 2017 to December 2018 NHSH Highland provided interpretation3 for over 7966 health, care and support appointments:-

Type of Service April 2017- March 2018 April 2018 – December 2018Face to Face interpretation

1829 1522

Telephone language interpretation

2474 1653

British Sign Language Interpretation

282 206

A Right to Speak – Augmentative and Alternative Communication Augmentative and Alternative Communication (AAC) is a term used to describe a range of aids (pictures, gestures, symbols, photographs and technological support including voice output communications aids) that can help people to get their message across when they find speaking difficult. AAC can help everybody to understand the world around them better.

The right to speak and to be heard is a fundamental human right4 as it is the key to an individual’s ability to be autonomous, and to make choices and decisions. Communication is a two way process. It involves information going in two directions (information being expressed and information being understood) and failing to meet the needs of people who use or need AAC results in widening inequalities because of the difficulties accessing services including healthcare. Early intervention with AAC provision and support is crucial to reducing inequalities for the individual who needs to use AAC.

NHS Highland (and all other Health Boards) now have a legal duty5 to provide anybody who has lost their voice or has difficulty speaking with communication equipment and support on how to use it.

NHS Highland continues to recognise that individuals who use AAC are included, free from discrimination and live in an environment that recognises their needs and adapts accordingly. We also continue to work to ensure that people who need or use AAC have access to specialist assessment where appropriate, and the provision, repair and reassessment of their AAC systems.

During the period of "A Right to Speak Project" NHS Highland trained three Talking Mats trainers in North Highland and rolled out training to staff from a wide variety of Third Sector Organisations. "A Right to Speak" also funded the development of a toolkit for Adults with Learning Disabilities to enable adults with communication difficulties to be involved and included in decisions made regarding their care and support, and to provide a reviewing tool to support service providers to be responsive and proactive to their service users needs and support requirements. This Toolkit has been developed and piloted and there are plans to roll this out over the coming months.

3 The most frequently used languages are Arabic, Bengali, Cantonese, Hungarian, Latvian, Mandarin, Polish, Romanian, Russian and Spanish. 4 Article 19 of the Universal Declaration of Human Rights 5 Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016

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Access Support CardsNHS Health Scotland have developed a credit card sized Access Support Card to support service users who have additional support needs due to disability or long-term conditions. It is recognised that some disabilities or conditions may be visible but many are not immediately apparent. The card can be used to alert staff about any additional support required by handing it over to receptionist when attending for an appointment.

Prior to the proposed national roll-out of the cards, NHS Highland was invited to participate in to trial these cards in an acute hospital setting. At the time of writing, the trial is yet to commence but it is anticipated that NHS Highland will be reporting back to NHS Health Scotland at the end of the trial period with a view to supporting the roll-out nationally.

Stonewall ChampionStonewall is Europe’s largest lesbian, gay, bi and trans (LGBT) charity and NHS Highland is proud to be part of its Diversity Champion programme.6 This is an employers’ programme which demonstrates work undertaken in areas such as policy and practice. Staff from across organisations also complete an anonymous survey about their experiences and inclusion at work.

NHS Highland has been a Stonewall Diversity Champion since 2016 expressing our commitment to working closely with our staff and the community to drive cultural change. We want our LGBT+ staff to work in an environment free from prejudice and bias where they feel valued and respected regardless of their identity.

NHS Highland makes an annual submission to the Stonewall Workplace Equality Index which is a benchmarking tool to assess an organisation’s work on LGBT equality. We receive a score which helps see how we have performed in comparison with others in the sector and against Stonewall’s best practice guidelines. Stonewall have reported that 2019 (submissions made in September 2018) has been the most competitive year since the introduction on the WEI in 2005. NHS Highland’s score improved by 13.5 points and 40 places.

WEI submissions 2017 2018 2019Ranking 328 318 278Score 41 40 53.5

NHS Highland recognises that although being a Stonewall Diversity Champion is illustrative of our commitment, more progress is needed as we want to build on creating an inclusive and accepting environment not only for staff but for service users/ patients and the wider community by driving positive societal change so we will continue to strive to raise the profile and awareness of trans and non-binary identity and expression.

6 https://www.stonewall.org.uk/diversity-champions-programme

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2.4 Care

Near MeNHS Near Me is a new video consulting service which aims to provide outpatient consultations as close as possible to home. NHS Near Me appointments take place either at your home or at a local NHS clinic where patients see their consultant or other specialist via video link.

Development of a Screening Awareness Community Champion and Volunteer ProgrammeIn 2018, NHS Highland’s were successful in obtaining a Scottish Government grant award to develop a Community Volunteer/Champion model to support the delivery of “Screening Awareness” in communities where acceptance of screening is known to be low (high participation rates in screening programmes are associated with higher population benefits).

Participation in Abdominal Aortic Aneurysm, Bowel, Breast and Cervical screenings across Highland meets or exceeds the national minimum standards in all cases; however steep inequality exists in uptake for those in our most deprived areas (as detailed in the following tables)

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Table1:NHS Highland bowel screening % uptake by all persons by deprivation category. 1st

November 2015 – 31st October 2017.

SIMD 1 SIMD 2 SIMD 3 SIMD 4 SIMD 5 Highland Scotland KPI

44.9% 53.7% 60.2% 63.4% 67.5% 59.8% 71.9% 60%

Table 2:NHS Highland cervical screening % uptake in women aged 25 – 64 by deprivation category. 1st April 2017 – 31st March 2018. Uptake is age appropriate based on being screened in the appropriate period (3.5years or 5.5 years).


65.8% 70.4% 74.7% 77,2% 80.9% 74.6% 72.8% 70%

Table 3:NHS Highland abdominal aortic aneurysm screening % men tested turned 66 in year ending 31 March 2017 by deprivation category.


77% 80.8% 88.2% 87.7% 88.9% 86.1% 84.4% 70%

NHS Highland are trying to address inequality in uptake of screening programmes as screening is key to detecting disease early and reducing health inequalities in cancer/health outcomes. To this end, 2 screening engagement practitioners have been recruited to identify, develop, train and support volunteers to promote the uptake of screening in our most deprived areas. 8 volunteers have been recruited and 17 targeted engagement events have been delivered to raise awareness and provide information on screening. The project has also successfully recruited and trained 3 members of staff to be screening champions in the communities in which they work. The project will continue to recruit and support volunteers and champions in 2019/20.

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2.5 Participation and empowerment

Awareness raising days and events International Day Against Homophobia, Transphobia and Biphobia (2017)

NHS Highland supported and promoted this campaign to both staff and members of the public by sharing resources both online and via display stand in Raigmore Hospital

ProudNess (2018)

NHS Highland supported and promoted the first LGBT+ Pride event in Inverness

LGBT History monthly (2019)

Along with promoting this event which has been running in Scotland since 2005, NHS Highland took the opportunity to seek to promote the commencement of a NHS Highland-wide LGBT+ staff network.

Volunteer Breastfeeding Peer Supporters NHS Highland has a band of over 50 volunteers who provide support to women by telephone, social media and through support groups. They offer evidence based information, support and encouragement to women and their families who choose to take part. The service is offered to all women

in Raigmore Hospital before discharge or later through the woman’s Infant Feeding Support Worker, midwifery or health visiting team. We have volunteers based throughout the NHS Highland area.

Infant Feeding Support WorkersThe Infant Feeding Support Workers are employed by NHS Highland and are part of the midwifery teams, but continue to provide support for breastfeeding mums when they transition to the Health Visiting Service at 10 days post birth. There is no restriction as to how long they are able to support women, with this support being available to mothers as long as they continue to breastfeed and feel they need the support.

Infant Feeding Support Workers are located in the community in identified areas of deprivation7 that historically have low breastfeeding rates.

7 Caithness, Alness, Invergordon, Fort William, Merkinch, Raigmore, Dingwall

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Highland Green Health PartnershipNHS Highland has been working with Scottish Natural Heritage, Highland Third Sector Interface and Highlife Highland to develop a Green Health Partnership. During 2018 the partnership developed a bid for national funding through the ‘Our Natural Health Service’ programme and was awarded £100,000 per annum over a three year period to develop the partnership and expand Green Health activity in the region.

Highland is renowned for its natural environment and wide range of opportunities for people to experience nature and the outdoors. Our natural assets have the potential to contribute to improving a range of health outcomes. It is the goal of the partnership to tackle inequalities of access to these outdoor opportunities therefore helping to tackle health inequalities, addressing issues of social isolation and supporting the general transformation needed to keep people healthier for longer.

The Green Health Partnership is providing a co-ordinated approach to developing initiatives, expanding the opportunities and use of the natural environment to support positive health outcomes and ease pressure on an already overstretched healthcare system. It will build on the good work already going on in Highland and help raise awareness within partner organisations about the potential benefits of green health initiatives. The partnership also aims to develop better connections between health and social care services and green health initiatives.

The Highland Green Health Partnership is one of only four area-wide partnerships being developed in Scotland. The following diagram outlines the agreed vision for the partnership.

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Hate Free HighlandHate Crime is motivated by hatred or prejudice on the grounds of race, religion, transgender identity, sexual orientation or disability.

There is an increasing awareness of the impact of hate crime on individuals and communities and although the hate crime figures in Highland are relatively low, there is concern that many incidents go unreported.

Police Scotland statistics 13/14 15/16 17/18All incidents 283 287 131Crime Incidents 146 130 94Non-crime Incidents 137 157 37

NHS Highland continues to work in close collaboration with partner agencies8 to raise awareness of hate crime and to encourage the reporting of hate crime incidents.

A series of practical measures have been set out to tackle and prevent hate crime in Scotland9 which focus on prevention, raising awareness and improving services. In order to support the work that is underway nationally, public sector organisations in the Highlands have set up the Hate Free Highland campaign to tackle prejudice and discrimination in Highland. It offers an online10 reporting facility whereby anyone can report non-urgent hate crime incidents that they perceive to be motivated by ‘hate’ associated with age, gender, disability, religion or belief, race, ethnic origin, sexual and sexual orientation or social background. The campaign works with community organisations to provide assistance to individuals to report hate crime issues faced by communities.

The availability of this website has been communicated to employees of NHS Highland as a means of support and is promoted more widely to the community by participating in events such as the Conversation Cafe event at Inverness College campus on 15 October 2018.

Gender based violence policy The Gender Based Violence Policy for Employees has been updated to provide a consistent framework for how managers respond to disclosures of abuse. The policy provides information for managers about what they must do and practical tips for supporting staff.

The policy includes two flowcharts to help guide managers through the process – one for responding to survivors of abuse and one for responding to perpetrators of abuse. The policy also provides confidential contacts and other sources of support, including Occupational Health.

8 The Highland Council, Highlands and Islands Enterprise, Police Scotland and High Life Highland9 https://news.gov.scot/news/next-steps-on-tackling-hate-crime10 https://www.highland.gov.uk/hfh/

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Members of the Personnel Team within Human Resource received training on Gender Based Violence to ensure that they too can respond consistently and appropriately to disclosures. An e-learning module is available and face to face training is also offered (and is mandatory for some staff) and further guidance is available on the intranet.

HR, Occupational Health and survivors of abuse have been involved in this policy refresh. Feedback has also been received Zero Tolerance, a Scottish charity working to end men’s violence against women by promoting gender equality and by challenging attitudes which normalise violence and abuse.

Working with partners NHS Highland has a long history of working in partnership with other local agencies and organisations from the public, community11, voluntary and private sector as well as our staff and service users. Partnership working, engagement and consultation are at the centre of how we wish to operate and help us decide what our priorities should be having taken account of national initiatives/targets and the whole community. NHS Highland is keen to engage with the public to get local residents’ input with regard to development, design and delivery of services.

Nationally, NHS Highland continues to be represented on the NHS Equality and Diversity Lead Network. This is a peer support network for equalities officers for all Scottish Health Boards which facilitates information sharing and discussion particularly around equalities issues.

Locally, NHS Highland has been collaborating with partners to prepare the Highland Outcome Improvement Plan. Mental health and wellbeing is one of the five key themes for Community Planning Partners who committed to delivering Suicide Intervention and Prevention training to 500 staff in 2019.

Alongside training, a suicide prevention App has been developed and rolled out to support the wider community. The app allows participants to complete a ‘Prevent Suicide’ safety plan with the help of a trained listener on a helpline such as Breathing Space, a health professional or with a friend or family member. It also includes telephone numbers for local and national help lines which can offer support in some situations where people are feeling distressed or suicidal and there is guidance on what members of the public can do to help someone they suspect is feeling suicidal.

11 Community Empowerment Act

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https://www.highland.gov.uk/news/article/11462/highland_community_planning_partnership_launch_suicide_prevention_app


2.6 Embedding equality within business functions

Procurement strategy All procurement activity is undertaken by NHS Highland Procurement’s Department in accordance with Scottish Procurement regulations and principles of transparency, fairness and equality of treatment and in line with the NHS Highland Procurement Strategy 2018-21. All contracts greater than £50,000 in value are advertised on the Scottish Government’s Public Contracts Scotland portal which is intended to help increase opportunities to a wider supplier base.

Where possible, equality and diversity considerations are built into how we procure our goods and services. When choosing suppliers, they must comply with current equality legislation in relation to employment. Suppliers are requested to take reasonable steps to ensure that this extends to any third parties acting on their behalf delivering the contract.

2.7 Conclusion and potential next steps

NHS Highland is working hard to ensure that equality is mainstreamed into working practices and policies. As a result much activity has taken place and snapshots are demonstrated throughout this report. We have made significant progress in some areas but acknowledge that there is more work to be done and that continue to make inroads everyone across the organisation has a duty to advance equalities including:-

Board members setting strategic direction, review performance and ensure good governance of the organisation.

Senior managers oversee the design, delivery, quality and effectiveness of the organisation’s functions.

Human resources staff building equality considerations into employment policies and procedures.

Policy makers building equality considerations into all stages of the policy making process including review and evaluation.

Communications staff ensuring relevant equality information is available and accessible.

Frontline staff meeting the needs of people from equality groups and those with protected characteristics.

Procurement and commissioning staff building equality considerations into the organisation’s relationships with suppliers.

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https://www.nhshighland.scot.nhs.uk/AboutUs/Procurement/Documents/NHS%20Highland%20Procurement%20Strategy%202018-21%20-%20Final.pdf

https://www.nhshighland.scot.nhs.uk/AboutUs/Procurement/Documents/NHS%20Highland%20Procurement%20Strategy%202018-21%20-%20Final.pdf


Equality & Diversity ChampionsLimited and diminishing resources can have an effect on what we would like to achieve. Often a direct result of limited resources is that what we would like to do may take longer to implement. We acknowledge that in order to adopt a person centred approach to health care it is crucial to seek engagement from those that use the service and consequently to listen to those views.

We need to invest in staff, volunteers and advocates who have an interest in all the various strands of Equality & Diversity. NHS Highland has a strong history of partnership working and recognises that this has been mutually beneficial to the organisation and ultimately to patients, those we support and staff. We could develop a network of people across our organisation and continue to get partners to be involved with input and leadership from a Board Member.

A review of the Equality Impact Assessment (EQIA) process Following the introduction of the Equality (Scotland) Act 2010 and associated Regulations, NHS Highland adopted a practice of completing EQIAs in order to assess and monitor policies, plans and functions. From our experience, creation and review of EQIAs was not as comprehensive as we had aimed for as very little uptake of the internal EQIA has been achieved. Whilst, attempting to make progress in this regard, further responsibilities were imposed by the Fairer Scotland Duty. Whilst we welcome the intent behind this additional duty, we were concerned that in practice the historic low uptake of EQIAs together with any perceived additional burden of completing socioeconomic impact assessments would be heightened by implementing an additional form of assessment.

NHS Highland are aware that NHS Health Scotland promote Health Inequalities Impact Assessments (HIIAs) however we adopted an approach whereby existing EQIA templates and guidance were revised and modified so that one process would address both the Equality Act and socio-economic duties (now the Fairer Scotland duties). Printed guidance is available for staff members and managers and additional training is available to assist staff in completing EQIAs and reviewing same.

NHS Highland could undertake a review as to whether the uptake and use of this new tool is fit for purpose and to ensure compliance with the duties in relation to equality, economic, social and environmental impacts.

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Section 3: Equality Outcomes Progress Report

3.1 Background

Outcomes are the changes that result for individuals, communities, organisations as a consequence of the action the organisation has taken. Outcomes can include short-term benefits such as changes in awareness, knowledge, skills and attitudes and longer-term benefits such as changes in behaviours, decision making or social and environmental conditions.

In 2013 we published our first set of Equality Outcomes for the period 2013-17. The Specific Duties require us to review progress in meeting equality outcomes every 2 years. In 2017 we decided to concentrate on 6 new outcomes which are specific to particular areas we would like to improve over the period from 2017 to 2021. We will now provide an update on progress made and identify further actions to be addressed over the second half of the reporting period.

It is important to note that our current equality outcomes are not the only outcomes NHS Highland has to support equality. The outcomes detailed below are illustrative of the priority areas for improvement within the next 2 years.

In April 2017 (updated August 2017) we set out 6 equality outcomes:

1. Increasing the diversity in leadership and workforce participation

2. Identified groups have improved experiences of accessing services and information

3. Identified groups of children and young people will benefit from improved access to mental health services and support

4. People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them

5. In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it

6. Community Planning Partnerships will work towards addressing socio-economic disadvantage as set out in the Local Outcome Improvement Plans

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Equality Outcome1: Increase diversity in leadership and workforce participation

Agreed action

Progress to date over the past 2 years and next steps Leadership

Continue to work as a Stonewall Diversity Champion to promote LGBT equality in the workplace

Activity: Promoting awareness days/events - for example

- LGBT History Month (February)- International Transgender Day of Visibility (March)- International Day Against Homophobia, Transphobia and

Biphobia (May)- Pride Month (June)- Transgender Day of Remembrance (November)

Stonewall Workplace Equality Index (WEI) completed in September 2017 and 2018

Stonewall Workplace Equality Index roundtable (2019) Stonewall staff survey promoted in 2017 and 2018 Developing protocol and guidance documents:-

- Supporting staff transitioning in the workplace- Transgender Respect!- Toolkit

Next steps: Participate in developing and drafting a national Once for Scotland

policy on supporting transgender staff in the workplace Meantime, promote local NHS Highland protocol and guidance Submit WEI in September 2019 with an aim to improve our score Promote the staff survey 2019 Promote awareness days/events Continue to promote a more LGBT inclusive environment for staff

and patients Increase awareness and support to improve the treatment of LGBT

staff and patients by focusing on data improvement to understand

Principal Officer Health Inequalities

Deputy Director of Human Resource

In partnership with:Stonewall

NHSH LGBT+ & Allies staff network

Draft Equality Outcomes & Mainstreaming Progress Report 2017-19


the impact on services and workforce Development of Trans Allies programme for NHS Highland/NHS

Scotland Establishment of LGBT employee network to contribute to inclusion

efforts in the workplace (potentially a national, digital LGBT staff network) to provide LGBT staff with a forum for building community, identifying needs of LGBT staff and patients and feeding policy suggestions back into the organisation

Address health inequalities in relation to- Access to gender identity services- LGBT mental healthcare (especially for young people)- End of life care for LGBT people

Increase the number of staff completing monitoring forms

Activity: Pilot running of HR database with self service modules. Delays to further roll out due to national delay with interface development. No significant improvement in data quality seen.

Next steps: Specific action to change collection process to be part of

payroll/e:ESS interface project and roll-out. Exit Interview Policy to be amended to support exit questionnaire

use through e:ESS

HR systems and project manager

Carer Positive Award Activity: Maintained our accreditation to the Carer Positive Award –

currently level 1 “engaged”

Potential next steps: Continue to raise awareness of the growing numbers of people who

work and have caring responsibilities Progress from level 1 to level 2 “established” with a view to

progressing to level 3 “exemplary” Encouraged carer within the organisation to identify themselves as

Medical staffing manager

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a carer and to access support they need. As a holder of the Carer Positive kite mark we are able to use the

logo, which acts as a symbol that NHS Highland supports carers at work, builds reputation as an 'employer of choice', and encourages potential applicants who are carers to seek employment with NHS Highland. This could be included on our recruitment pages and has also been added to all our stationery templates.

Policy review focused on HR Policies, including work life balance policies

Activity: All Human Resources and Workforce policies are developed in

partnership with staff side colleagues. Prior to adoption, a policy must be approved by:- Human resource policies by Partnership Forums- Clinical and nursing/midwifery policies by Clinical Forum- All other policies by the Senior Management TeamPolicies are developed in line with the Policy Development, Review and Control Policy and are accompanied by EQIAs to identify and address existing or potential inequalities

Review undertaken of all work-life balance policies including:-- Reduced Working Year Policy- Employment (Career) Break Policy- Annualised hours Policy- Retirement Policy- Special Leave Policy- Shared Parental Leave Policy- Parental Leave Policy- Standards of Dress Policy

Next steps: Nationally, the Scottish Workforce and Staff Governance

Committee have been tasked with replacing the current Partnership Information Network (PIN) policies with Once for Scotland polices

HR Sub Group

HR Manager

Highland Partnership Forum

Workforce policy programme

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by 2020. The overriding purpose of the policy review is to create single/ standardised policies

The existing suite of policies (15 in total) have been divided into three groups:-- Core policies (grievance, conduct, capability, prevention of

bullying and harassment, whistle blowing, promoting attendance, managing health at work)

- Supporting employment policies- Wellbeing & equality policies (Embracing Equality, Diversity and

Human Rights, Gender based violence, supporting the work-life balance)

Until the new Once for Scotland policies are signed off, existing PIN policies will continue to apply

Encourage staff to complete the Equality and Human Rights training module

Activity: All staff (including Senior Managers and Board members) are

required to complete the mandatory Equality & Human Rights training module every three years.- 2017 compliance rate: 49%- 2018 compliance rate: 68%

Appointed Training Compliance Officer from 2018 to identify employees to promote compliance and to provide guidance on all the 6 statutory and mandatory training requirements

Developed and implemented learnPro Course Booking System (CBS) which enables line managers to create an online training plan for staff

In Argyll & Bute the Union are able to provide computer/training and/or support for staff who do not readily have access to a computer during working hours to complete the mandatory training

Improved staff awareness on equality issues, patient needs and improvement in practice

March 2019 a workshop was held for managers to look at aligning the EQIA paperwork with the A&B Council and NHS in the HSCP.

Highland Partnership Forum

Business Support Manager

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Speakers were present to review undertaking EQIA’s, socio-economic duty and promoting the Scottish Health support tool – ‘ The Role of Health and Social Care Partnerships in reducing health inequalities’ (NHS Health Scotland).

Next steps: Continue to issue internal communications to staff and managers to

increase completion rates 100% of new starts complete core statutory and mandatory

elearning within the first week of commencing employment and classroom training within two weeks of commencing employment (duties should be restricted until such time as training has been completed).

95% of existing staff to complete core statutory and mandatory elearning and classroom training/refresher requirements within the required timescales

IT access continues to be inaccessible or difficult to access for some staff

Support to be provided for all staff to complete mandatory training during work time

Continue to offer training for new inductions as well as refresher training every three years for all staff to allow for staff to have increase confidence in recognising and responding to the needs of people from the respective protected characteristic groups

Disability Confident Award Activity: Maintained our accreditation to the Disability Confident Employer

Award (level 2) which helps NHS Highland improve how we attract, recruit and retain disabled workers

Potential next steps: Progress from level 2 to level 3 – Disability Confident Leader Actively look to attract and recruit disabled people

Medical Staffing Manager

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Provide an inclusive and accessible recruitment process Encouraging our suppliers and partners to be Disability Confident

Increase education and employment opportunities for care experienced young people

Activity: Focus of CHAMPS Board (now Corporate Patenting Board as part

of the Highland Community Planning Partnership) has concentrated on engagement with young people

Market stall event at Inverness College campus Celebration event Family Firm has refocused its role and the co-ordinator and

employment advisor will sit within the Highland Council alongside economic development and employability colleagues

Next steps: Attendance at future events Promoting Family Firm Path for young people who are looked after

either at home or away from home

Child Health Commissioner

Equality Outcome 2 – Identified groups have improved experiences of accessing services and information

Agreed action

Progress to date over the past 2 years Leadership

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Responding to access support needs (ASN)

Participate in national working group to develop READ codes to identify Access Support Needs in primary care

and

Use quality improvement methodology to develop the identification and response to specific ASNs

Activity: A substantial amount of work has gone into progressing the

development of ASN systems both at individual Health Board level and nationally since this requirement was first highlighted by Audit Scotland in 2010. However, since the SCI Gateway ASN system was agreed (June 2017) it has proven challenging to move forward. This is primarily due to the fact that ASN e-Health systems development has no explicit ‘home’ within Scottish Government policy. The work spans multiple policy areas but has no dedicated funding or work stream to drive it forward and, as such, we have been unable to identify the necessary ‘ownership’ needed to test the developments outlined above and work towards making the system available. Consequently, all Health Boards have been unable to meet this outcome.

Next steps: The Scottish Government e-Health Division have agreed to work

with NHS Health Scotland and NSS to make the SCI Gateway ASN system available to Boards

Once the SCI Gateway ASN systems are available to health Boards, the on-going developments will be taken by individual Boards

Head of Planning and Performance


National Equality & Diversity Lead Network

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Develop British Sign Language Plan Activity: From July 2018 replaced the NES Deaf Awareness elearning

module with Highland Deaf Awareness module Engagement and consultation process carried out with members of

the BSL community Worked in partnership to develop joint actions with The Highland

Council Developed a Local NHS Highland BSL plan for 2018-24 Training since April 2017: 408 participants made up of 92 taking

part in face to face training; 80 completing NES Deaf Awareness elearning module, 90 completing Deaf Awareness training elearning module and 66 completing Sight Loss elearning module

Communication Support is available to D/deaf patients/service users as required. The Highland Council manages support for NHSH requirements.

Next steps: NHS Highland will contribute to a national progress report on the

BSL National Plan in 2020 Implement action points within the NHS Highland local action plan Promote use of contactScotlandBSL to assist communication

particularly with regard to making appointments Community engagement event(s) with Deaf BSL users and to

Deafblind people who require communication support Assist with setting up a steering group to monitor actions and

progress in the BSL local plan potentially with partner agencies as well as members of the BSL community

Review of Communication Support Services in conjunction with The Highland Council


In partnership with:The Highland Council

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Provide communication support for people who are D/deaf or hard of hearing

Activity: Review of communication support underway from 2018

Next steps: Review of communication support extended into 2019 Investigate the suitability of trialling video interpreting service for

BSL Monitor use of service Annual survey of service users Improving communication support in rural areas Sustainability



Provide interpretation to service users where appropriate

Activity: Training provided since 2016 – “Working with interpreters” Reviewed (but awaiting approval)

- Interpretation guidance for NHS staff- Guidance for translation of written information- Policy for the Translation of written information and accessible

publications- Language charts

Next steps: Monitor use of service Survey of staff/service user experience Continue to offer training on “Working with Interpreters” Promoting staff guidance on how to arrange interpretation,

translation, communication support and accessible information


Addressing sensory impairment in care homes

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Roll out sensory impairment assessment to all care home residents

and

Improve identification of sensory impairment on admission to care homes

Activity: Upon admission review of existing assessments is undertaken Updates to Personal Outcome Plans made if necessary If a hearing/sight impairment is identified, to provide appropriate

equipment (for example lights, flashing alarms)

Next steps: NHS Highland is undertaking a review of sensory services with an

intention to align with See Hear Strategy 2014. Once the review is completed, then next steps will be identified.

See Hear Improvement Group

Project Manager Adult Social Care

Improving the experience of care for LGBT service usersDevelop an inclusive communication toolkit for use in primary care

Activity: Surveyed service users on experiences of care Developed a toolkit for primary care Guidance developed with input from Stonewall Training session to Occupational Health and Human Resource staff

members

Next steps: Promote local protocol on Supporting Transgender Employees in

the Workplace and Transgender Respect! Promote the toolkit for primary care Offer face to face training as required Provide guidance to staff so that they are confident in meeting the

needs of service users or colleagues who have/are transitioning


Senior Health Improvement Specialist

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Equality Outcome 3 – Identified groups of children and young people will benefit from improved access to mental health services and support

Agreed action


Increased investment in services for children and young people with Learning Disabilities and Autistic Spectrum Disorder

Activity: NHS Highland and The Highland Council have been working

together and reviewed the assessment process and diagnostic pathway for children and young people who have neurodevelopmental difficulties (ASD, ADHD, DCD and FAS)

A new multi-agency service was set up and the team includes community paediatricians, speech & language therapists, occupational therapists, clinical and assistant psychologists

Submission to NHS Education for Scotland (NES) for funding to increase psychology time for Neurdevelopmental Assessment Service (NDAS)

Partnership work with The Highland Council and Adolescent Mental Health Services/Looked After Children Development Project Children and young people who become looked after by their local authority are likely to have experienced early adversity, trauma and disruptions to care giving which can significantly impact their wellbeing, relationships, development and ability to engage with educational opportunities.

Member seminars on mental health services in Highland held during 2018, including services for young people and involvement of NHS colleagues.

Next steps: Awaiting confirmation of funding and once granted to move forward

with recruitment process

CAMHS Service Manager

Lead Consultant Clinical Psychologist



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http://forhighlandschildren.org/1-childrensplan/strategy_41_758747666.docx

http://forhighlandschildren.org/1-childrensplan/strategy_41_758747666.docx


A new outreach team to deliver services in rural areas

Activity: Staff have been recruited and the service is being delivered

Next steps: Consolidate the team and the interfaces with the North of Scotland

Tier 4 network



Use quality improvement methodology (RPIW) to develop a new pathway for CYP with neurodevelopment disorders

Activity: A Rapid Process Improvement Workshop (RPIW) was undertaken

and as a result a new neurodevelopmental assessment service (NDAS) established

Next steps: Further refining of approach to ensure family supportive trauma

informed, attachment led approach and inclusion of learning disability in the assessment process




Equality Outcome 4 – People better recognise and understand prejudice-based incidents and hate crimes and feel confident reporting them

Agreed action


Review and launch new Hate Free Highland website

Activity: Monitored use of website Stall at Hate Free Highland conversation cafe event October 2018

Next steps: In partnership with the Highland Council, Highlands & Islands

Enterprise, Highlife Highland and Police Scotland to review the existing website and materials with a view to refreshing and updating these

Consideration to be given to using social media Promote Hate Free Highland website, event and campaigns


Working in partnership with:The Highland CouncilHighlife HighlandHighlands & islands Enterprise

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Promote Third Party Reporting Centres Prepare and disseminate information on reporting Hate Crime

Police Scotland

Identify and train Third Party Reporting Organisations (TPROs)

Activity: Work to identify and train Third Party Reporting Organisations is in

its early stages as a review of the TPRO locations is being undertaken by Police Scotland

Next steps: Support Police Scotland with review of TPROs Continue to promote Hate Free Highland campaign Raise awareness among staff of how to report a hate incident

locally Raise awareness of reporting centres locations

Safer Highland Group

Community Safety, Public Engagement and Equalities Committee

Raise awareness of hate incidents and hate crime Activity: Stall holder at Proud Ness event on 06 October 2018 Stall holder at Hate Free Highland event on 15 October 2018 Attendance at the hate crime event on 06 December 2018

Next steps: Participate in community events and stakeholder events An annual event/stall during Hate Crime week


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Equality Outcome 5 – In Highland, all individuals are equally safe and respected, and women and girls live free from all forms of violence and abuse and the attitudes that help perpetuate it

Agreed action


Clear guidelines to support staff experiencing gender-based violence and tackle perpetrators

Activity: Gender-based violence guidelines Clinical governance – DATIX incidents recorded Gender-based violence guidelines available on the HVAWP

website

Next steps: NHS Highland and the Highland Council partnership working on

Equally Safe at Work project

Deputy Director of HR

Refresh priorities and measures for VAW Activity: Implemented national performance framework Identified additional local performance measures

Next steps: Work with CHAMPS to develop VAW resources for use in care

settings Develop VAW sessions for use by other agencies Develop practitioners network to support each others, share

resources and good practice

Chief Executive

VAW Partnership

Delivering the VAW training programme and evidence the impact of VAW training

Activity: The Highland Violence against Women Partnership Training Report

for 2017/18 details that this year the recruitment of a part-time training officer has enabled a steady increase in the training numbers (65 courses, 588 delegates of which 175 were NHS Highland employees). In January 2018 a refresher course for

VAW development & training manager

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https://www.hvawp.scot.nhs.uk/contact/

https://www.hvawp.scot.nhs.uk/contact/


Routine Enquiry and MARAC courses Bespoke training sessions and workshops resulted in 274

participants from multiple services including Accident & Emergency staff, Community Mental Health Teams, Education staff, third sector agencies. Participants report that they “feel more informed about gender inequality and its impact and demands”.

3 day training for trainers course was delivered to a group of 15 colleagues

Next steps: Training programmes continue to be offered to all public services

including practitioners in statutory (universal and specialist) and third sector services

Trainers who attended the training for trainers course will deliver training throughout the organisation

Partnership training will be provided on demand and where resources allow

A full evaluation framework to be developed for 2019/20 including impact of training on service

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Equality Outcome 6 – Community Planning Partnerships will work towards addressing socio-economic disadvantage as set out on the Local Outcome Improvement Plans

Agreed action


Community Planning Partnerships will work towards addressing socio-economic disadvantages as set out in the Local Outcome Improvement Plans

Activity:NHS Highland is a key partner is two community Planning Partnerships

- Highland- Argyll & Bute

HighlandIn partnership, developed a Highland Outcome Improvement Plan (HOIP). 5 main themes identified:

1. Poverty reduction2. Community participation and dialogue3. Infrastructure4. Community Safety & Resilience5. Mental Health & Wellbeing

Cross-cutting themes include:- Employability, Employment & Skills Development- Community Investment & Development- Digital Inclusion- Equality of Opportunity & Inclusion

Locality Plans are in the developmental stage with a focus on encouraging completion of the Place Standards Tool

Community Engagement events have taken place to discuss priorities for locality plans

Health inequalities checklist prepared and made available to CPPs Engagement across Highland with communities and a range of

interest groups in order to identify the key outcomes and priorities for the Highland Outcome Improvement Plan. Engagement reports

In partnership with including:The Highland CouncilHIEPolice ScotlandSFRSHTSI

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can be found here: www.highlandcpp.org.uk/publications-and-reports.html

Next steps: Promote use of health inequalities checklist which has been

prepared in conjunction with The Highland Council. Public Health representatives continue to provide support (including

health inequalities training and community engagement) to each of the 9 existing Community Partnerships as well as to the overarching Highland Community Planning Partnership.

Developing an effective approach to align Equality and Socio-economic impact assessments

Agreement and implementation of Delivery Plans for each HOIP outcome

Further development of Locality Plans

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http://www.highlandcpp.org.uk/publications-and-reports.html

http://www.highlandcpp.org.uk/publications-and-reports.html

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ANNEX 2: EMPLOYEE DATA AND INFORMATION

Employee Protected Characteristics Data and Analysis

Data Quality Issues and ActionsNHS Highland employee data relating to protected characteristics is held in the electronic Employee Support System (e:ESS). Although e:ESS went live in 2013, the use of employee and manager self- service functionality within the system remains limited. This functionality is used by employees to update, amongst other things, their protected characteristic information. For most protected characteristics (notable exceptions being age and gender), somewhere in the region of 40% of the information is unknown because it has not been provided, either by declining to provide it or because they have not been asked. This figure has remained consistent over the last 3 years. The key action, therefore, in relation to our Equalities Duties in respect of employees, is to improve the quality of the employee equalities data we hold.

To improve the quality of our equalities data, we committed in the last action plan to roll out across NHS Highland the elements of Employee Self Service that will allow staff to update their Equalities information. Unfortunately this has not been possible for a number of reasons. A refreshed project is underway to implement manager self service for e:ESS. This in itself will not improve the quality of the data held. It will, however, mean the current process for collecting equalities information will change. The project team will, therefore, be tasked with identifying the least burdensome process for collecting equalities information.

Further work is required to increase the number of employees completing leavers questionnaires in the system, thus allowing us to collate and report equalities and leavers information from one source.

The work required to link absence information to equalities data has been delayed for NHS Highland. The interfaces that will allow this information to be collated accurately and reportable from one source will be implemented in May this year and we will run a dummy set of data in May 2020.

The workforce profile information presented below covers 3 years from January 2016 to January 2019. Where there is no trend information, the data presented represents a snapshot in time at 01 January 2019.

Draft Equality Outcomes & Mainstreaming Progress Report 2017-19


Workforce Protected Characteristics Data

Age Profile (headcount excluding Bank)

0

500

1000

1500

2000

2500

3000

3500

4000

2016 2017 2018 2019

16-19

20-29

30-39

40-49

50-59

60+

The above graph shows the trend in age group profile over the last 3 years from Jan 2016 to Jan 2019. Significant further decreases in the number of employees in the 60+ and 50-59 age ranges can be seen in the last 2 years can be seen with an accompanied increase in the 20-29 year olds, with a smaller rise in the number of 30-39 year olds. Although this represents an improvement we still face a significant workforce risk with the number of employees over 50 and approaching potential retirement age.

Table 1 below shows the number of applicants in each of the age bands along with the numbers appointed. This clearly shows a high proportion, 37%, of all applicants in the under 30 age bands. It also demonstrates that 30% of appointees are under the age of 30, the largest group by some margin. It should be noted, however, that the conversion rate (percentage of age group appointed) for this group is just 11.5% and for those under 20 it is just 5%. The best conversion rates are seen in the 35-39, 40-44 and 50-54 age bands.

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Table 1

Age Band No of Applicants No Appointed Conversion Rate<20 290 14 4.83%20-24 961 56 5.83%25-29 1018 60 5.89%30-34 722 57 7.89%35-39 725 41 5.66%40-44 640 56 8.75%45-49 782 51 6.52%50-54 739 53 7.17%55-59 540 31 5.74%60-64 186 13 6.99%65+ 219 11 5.02%DOB not given 52 1 1.92%

We are working closely with education providers to increase the number of opportunities available to younger people wishing to enter a career in health and social care, including modern apprenticeships and access to nursing support. It should be noted that the biggest staffing group in NHS Highland is nursing. Entry to this profession is through a degree which will of course impact on the age of recruitment for these types of post.

Gender (Postholders Excluding Bank)

Table 2

Employments by Gender 2016 2017 2018 2019Female 8365 8460 8385 8258Male 1769 1760 1737 1656

Table 2 above shows the gender profile within NHS Highland. In common with other employers in the health and social care sectors, we have a significantly higher proportion of female employees (82.8%). The profile masks a high degree of vertical and occupational segregation of female employees across job families and pay bands as demonstrated in Table 3.

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Table 3 – Employments by Agenda for Change Band and Gender

Agenda for Change Employees Female Male Grand TotalBand 1 95 18 113Band 2 1787 385 2172Band 3 944 131 1075Band 4 774 118 892Band 5 1711 197 1908Band 6 1200 219 1419Band 7 594 122 716Band 9 1 1Band8A 138 40 178Band8B 57 25 82Band8C 23 12 35Band8D 7 3 10Not Assimilated to AFC 928 385 1313

Just under 90% of staff at Band 5, for example, are female, compared to 68% for Band 8B and 8C, significantly higher paid bands.

The breakdown of gender across job families below demonstrates significant occupational segregation. Almost 100% of dental support staff are female, with very high proportions of women seen in nursing and midwifery, social care, allied health professions and administration. Higher paid occupations, such as medical and dental and senior management show a more equal split between genders. Support services, which includes domestic services, portering and estates, and Health Care Sciences each have similar proportions of females, around 61%. This occupational segregation has a significant impact on the Gender Pay Gap reported later in this paper.

Table 4 Employments by Gender and Job Family

Job Family - Gender Female Male Female MaleADMINISTRATIVE SERVICES 1536 222 87.37% 12.63%ALLIED HEALTH PROFESSION 633 81 88.66% 11.34%DENTAL SUPPORT 215 1 99.54% 0.46%HEALTHCARE SCIENCES 198 130 60.37% 39.63%MEDICAL AND DENTAL 251 281 47.18% 52.82%MEDICAL SUPPORT 6 3 66.67% 33.33%NURSING/MIDWIFERY 3389 326 91.22% 8.78%OTHER THERAPEUTIC 214 42 83.59% 16.41%PERSONAL AND SOCIAL CARE 500 45 91.74% 8.26%SENIOR MANAGERS 21 16 56.76% 43.24%SUPPORT SERVICES 665 425 61.01% 38.99%Not AFC 630 84 88.24% 11.76%

In addition the proportion of part time workers who are female is significantly higher across all job families than their male counterparts, as demonstrated in Table 5 below. This has had a further effect on total earnings for female employees. The percentage of female medical and dental employees has increased significantly

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compared to men in the last 2 years. This has had a further effect on total earnings for female employees.

Table 5 Part time and Whole Time Employments by Gender and Job Family

Female MaleJob Family Part TimeWhole Time Part TimeWhole TimeADMINISTRATIVE SERVICES 810 726 40 182 52.73% 18.02%ALLIED HEALTH PROFESSION 359 274 17 64 56.71% 20.99%DENTAL SUPPORT 141 74 1 65.58% 0.00%HEALTHCARE SCIENCES 79 119 9 121 39.90% 6.92%MEDICAL AND DENTAL 155 96 84 197 61.75% 29.89%MEDICAL SUPPORT 3 3 1 2 50.00% 33.33%NURSING/MIDWIFERY 1999 1390 70 256 58.98% 21.47%OTHER THERAPEUTIC 103 111 7 35 48.13% 16.67%PERSONAL AND SOCIAL CARE 355 145 28 17 71.00% 62.22%SENIOR MANAGERS 2 19 1 15 9.52% 6.25%SUPPORT SERVICES 509 156 108 317 76.54% 25.41%Not AFC 449 181 33 51 71.27% 39.29%

Female MalePart Time

Table 6 below highlights the recruitment conversion rates by Gender. It demonstrates that we continue to recruit more women than men with a male conversion rate of only 7.82% compared to 13.4% for women.

Table 6

Age Band No of Applicants No Appointed Conversion RateFemale 5495 367 6.68%Male 1357 76 5.60%Not Given 22 1 4.55%Grand Total 6874 444 6.46%

However, as with the current workforce profile, there is significant variation in conversion rates across the different job families as illustrated in the table below. Conversion rates are significantly higher for females in the Allied Health Professions, Nursing and Other Therapeutic which includes Pharmacy and Psychology.

Table 7

Job Family Female Conversion Rate Male Conversion RateAdministrative Services 5.53% 4.97%Allied Health Profession 9.30% 5.08%Dental 0.00% 0.00%Dental Support 0.00% 0.00%Healthcare Sciences 5.08% 6.71%Medical 10.00% 0.00%Nursing/Midwifery (Registered) 10.00% 6.48%Nursing/Midwifery (Unregistered) 4.44% 1.54%Other 0.00% 0.00%Other Therapeutic 6.67% 1.72%Personal and Social Care 6.35% 10.34%Support Services 7.41% 6.74%

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Disability

Table 8 below highlights the reporting issues mentioned at the start of this appendix. As at 1 January 2019, the disability status of 40% of our employees is unknown.

As well as the data quality work mentioned above, we will work with colleagues in Occupational Health to promote reporting in relation to disability by employees following new diagnoses.

Table 8

2016 2017 2018 2019Declined 24.95% 24.83% 25.11% 25.51%No 57.67% 58.49% 59.00% 59.43%Not given 16.64% 15.96% 15.18% 14.34%Yes 0.74% 0.71% 0.71% 0.73%

Tables 9 and 10 below outline the extent of occupational and vertical segregation of employees with a disability. There is no clear pattern evident across other band or job families. For example, over 4% of Band 1 employees classify themselves as disabled as does over 4% of Band 8b employees. This lack of a clear pattern is in part due to the small numbers involved. An improvement in the quality of the data, as discussed above, will enable us to draw conclusions with more confidence than we are able to do currently.

Table 9

Disability Yes % No % Declined % Not Declared

%

ADMINISTRATIVE SERVICES 31 1.66 1239 66.54 372 19.98 220 11.82

ALLIED HEALTH PROFESSION <5 * 504 66.23 172 22.6 81 10.64

DENTAL SUPPORT <5 * 167 78.77 33 15.57 11 5.19

HEALTHCARE SCIENCES <5 * 239 71.13 79 23.51 15 4.46

MEDICAL AND DENTAL <5 * 584 69.61 123 14.66 131 15.61

MEDICAL SUPPORT - - <5 * <5 * <5 *

NURSING AND MIDWIFERY - - <5 * <5 * <5 *

NURSING/MIDWIFERY 39 .82 3437 72.63 843 17.81 413 8.73

OTHER THERAPEUTIC <5 * 173 67.05 58 22.48 24 9.3

PERSONAL AND SOCIAL CARE <5 * 82 11.01 358 48.05 304 40.81

SENIOR MANAGERS - - 18 48.65 15 40.54 <5 *

SUPPORT SERVICES 14 1.06 724 54.64 358 27.02 229 17.28

Numbers less than 5 have been suppressed for confidentiality

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Table 10

Yes % No % Declined % Don`t Know

%

Band 1 <5 * 76 51.7 47 31.97 20 13.61Band 2 22 .7 1863 59.5 701 22.39 545 17.41Band 3 13 .97 754 56.18 364 27.12 211 15.72Band 4 9 .91 563 57.04 278 28.17 137 13.88Band 5 31 1.28 1751 72.27 425 17.54 216 8.91Band 6 10 .63 1132 71.55 316 19.97 124 7.84Band 7 9 1.2 548 73.26 145 19.39 46 6.15Band 8A <5 * 130 69.52 41 21.93 15 8.02Band 8B <5 * 51 58.62 27 31.03 8 9.2Band 8C <5 * 28 73.68 6 15.79 <5 *Band 8D - - 9 81.82 - - <5 *Band 9 - - - - <5 * - -Not AfC/Not Known Band <5 * 854 37.49 942 41.35 479 21.03

Numbers less than 5 have been suppressed for confidentiality

The application rate from disabled candidates is low at just 2.4% of all applicants, compared to the 23% of adults living with a limiting condition within NHS Highland board area.

As seen in table 11 below, the applicant to successful candidate conversion rate is 4.18% for disabled candidates, lower than that for those stating they do not have a disability (6.56%). Although the conversion rate is lower for those with a disability the gap to the conversion rate for those who do not have a disability has reduced by around 6%.

NHS Highland has recently been awarded the Disability Confident Employer award and is committed to achieving the core actions required to be a Disability Confident Leader. We expect these actions to have a positive effect on the number of applications from disabled candidates and improve the conversion rate.

Table 11

Disability Unsuccessful Applicants Successful Applicants Conversion RateYes 252 11 4.18%No 6157 432 6.56%Prefer not to say 21 1 4.55%

Transgender

Table 12 outlines the percentage of employees identifying as Transgender or Transsexual.

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Table 12

Transgender 2016 2017 2018 2019Declined 35.04% 35.35% 35.55% 35.77%Don`t Know 10.80% 9.55% 8.71% 8.01%No 54.09% 55.02% 55.66% 56.13%Yes 0.07% 0.07% 0.08% 0.08%

Sexual Orientation

Table 13 outlines the percentage of employees identifying as gay, lesbian, bi-sexual or heterosexual.

Table 13

Sexual Orientation 2016 2017 2018 2019Heterosexual 54.78% 55.57% 56.18% 56.76%LGBT 1.10% 1.10% 1.05% 0.98%Not declared 21.66% 20.67% 19.88% 19.27%Other 0.24% 0.25% 0.22% 0.21%Prefer not to say 22.22% 22.42% 22.67% 22.78%

Although the numbers are very small and again highlight the data quality issues faced, the figures reported have remained steady over the last 3 years for employees identifying in each category. The key priority is to encourage full reporting.

Table 14 below provides numbers and conversion rates of applicants identifying as gay/lesbian/bi-sexual. Compared to the heterosexual conversion rate, gay/lesbian/bi-sexual applicants are less successful at securing an appointment.

Table 14

Unsuccessful Applicants Successful Applicants Conversion RateHetrosexual 5902 412 6.53%LGBT 133 11 7.64%Not declared 213 13 5.75%Other 2 0 0.00%Prefer not to answer 180 8 4.26%

The numbers relating to Transgender applicants are too small to provide any meaningful data to analyse.

Ethnicity

Table 15 below outlines the percentage of employees identifying themselves as members of an ethnic group. Due to the small numbers involved, and following the Equalities and Human Rights Commission approach, Black and Ethnic minority groups have been aggregated.

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Table 15

Ethnicity 2016 2017 2018 2019Black and Ethnic Minority 1.10% 1.12% 1.09% 1.03%Not Declared 23.36% 22.50% 21.61% 20.83%Prefer not to answer 15.17% 15.18% 15.38% 15.42%White - Irish 0.83% 0.79% 0.75% 0.71%White - Other 2.63% 2.65% 2.67% 2.74%White - Other British 10.48% 10.59% 10.64% 10.62%White - Polish 0.01% 0.01% 0.01% 0.01%White - Scottish 46.43% 47.15% 47.86% 48.64%

As can be seen from the data above employees identifying with non-white ethnic groups has slightly decreased as a proportion of the workforce over the last 3 years. Over the same period the percentage of White Other employees has slightly increased, despite fears that employees from the European Union may leave due to fears over Brexit.

These figures mask, however, a clear occupational segregation within and across ethnic groups, as shown in table 16, although again there are small numbers involved. For example, 22% of Asian Others are employed within Support Services, compared to 14.4% White- Other and just 9.35% of White British employees. Medical and Dental employees make up 19.59% of White Other employees, compared to 6.5% of the British White Workforce. An improvement in the quality of the data as discussed above, will enable conclusions to be drawn with more confidence in the future.

Table 16

Job Family Black and Ethnic Minority White Not Declared Prefer not to answer Percentage BME

ADMINISTRATIVE SERVICES <5 1489 263 308 0.24%

ALLIED HEALTH PROFESSION 6 583 106 113 0.74%

AMBULANCE SERVICES <5 <5 <5 <5 0.00%

DENTAL SUPPORT <5 195 12 21 0.44%

HEALTHCARE SCIENCES 6 254 25 53 1.78%

MEDICAL AND DENTAL 18 654 172 137 1.83%

MEDICAL SUPPORT <5 <5 <5 <5 0.00%

NURSING/MIDWIFERY 80 4781 571 696 1.31%

OTHER THERAPEUTIC <5 194 33 42 0.74%

PERSONAL AND SOCIAL CARE <5 91 592 284 0.10%

SENIOR MANAGERS <5 21 <5 12 0.00%

SUPPORT SERVICES 18 866 321 245 1.24%

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Table 17

AFC Band Black and Ethnic Minority White Not Declared Prefer not to answer Percentage BMEBand 1 <5 92 25 34 1.95%Band 2 67 2307 840 539 1.79%Band 3 6 895 333 233 0.41%Band 4 <5 636 204 224 0.28%Band 5 21 2319 292 332 0.71%Band 6 11 1313 139 232 0.65%Band 7 <5 648 44 98 0.50%Band 8A <5 141 13 33 0.00%Band 8B <5 50 9 25 3.45%Band 8C <5 29 <5 <5 2.56%Band 8D <5 9 <5 <5 0.00%Band 9 <5 <5 <5 <5 0.00%

Table 18 shows numbers and conversion rates of applicants and successful candidates for a range of ethnic minority groups. The groups have been aggregated to show meaningful data, due to small numbers in the individual BME groups. The conversion rate for White Irish is skewed by the small numbers involved. It is clear that BME applicants experience a lower conversion rate than other applicants. This may be due to the small numbers involved but further qualitative work will be undertaken to understand this in more depth.

Table 18

Unsuccessful Applicants Successful Applicants Conversion RateBlack and Minority Ethnicity 357 16 4.29%

Not declared 18 1 5.26%Prefer not to answer 6 0 0.00%White 6049 427 6.59%

Religion

The data below shows the proportions of employees who claimed to identify with a particular religion or belief. Table 19 shows the number of employees identifying with a religion or belief has remained steady over the last 3 years, but there has been a corresponding increase in the number of employees whose religious beliefs are unknown. One would expect a large and complex workforce such as NHS Highland to follow national trends. The Scottish Government reports that in 2014, 44.5% of the Scottish Population did not identify with a religion or belief.12 In 2019 we are reporting only 22.63% which although an increase from 2016 still falls significantly short of the Scottish Population as a whole.

12 http://www.gov.scot/Topics/People/Equality/Equalities/DataGrid/Religion

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Table 19

2016 2017 2018 2019

Religion or Belief 35.05% 35.56% 36.13% 36.41%

No Religion or Belief 21.46% 22.08% 22.30% 22.63%

Not declared 25.54% 24.20% 23.23% 22.72%

Prefer not to answer 17.95% 18.16% 18.35% 18.24%

Again the figures above mask occupational segregation within and across religious groups. Just over 6% of the Medical and Dental Job family identify as holding a non Christian religion. This contrasts with just 2% of all Nurses and Midwives identifying with a non-Christian religion or belief and 1.5% in Administrative Services.

The table below highlights the number of applicants and successful candidates along with the conversion rate for those identifying with a religion or belief and those who do not. Again the data has been aggregated to provide meaningful data due to small numbers in some of the religious groups on which we collect data. The data shows a higher conversion rate for those identifying with a religion/belief compared to those who do not identify, although again, this could be due to the very small numbers involved. The combined conversion rate for unknown categories and no religion/belief is 6.57%, comparable to the conversion rate for those identifying with a religion or belief.

Table 20

Unsuccessful Applicants Successful Applicants Conversion RateReligion or Belief 5898 409 6.48%No Religion or Belief 88 1 1.12%Not declared 208 20 8.77%Prefer not to answer 236 14 5.60%

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Equal Pay Statement

This statement has been agreed in partnership and will be reviewed on a regular basis by the NHS Highland Partnership Forum and the Staff Governance Committee.

NHS Highland is committed to the principles of equality of opportunity in employment and believes that staff should receive equal pay for the same or broadly similar work, or work rated as equivalent and for work of equal value, regardless of their age, disability, ethnicity or race, gender reassignment, marital or civil partnership status, pregnancy, political beliefs, religion or belief, sex or sexual orientation.

NHS Highland understands that the right to equal pay between women and men is a legal right under both domestic and European Law. In addition, the Equality Act 2010 (Specific Duties) (Scotland) Regulations require NHS Highland to taking the following steps:

Publish gender pay gap information by 30 April 2013

Publish a statement on equal pay between men and women by 30 April 2013, and to include the protected characteristics of race and disability in the second and subsequent statements from 2017 onwards.

It is good practice and reflects the values of NHS Highland that pay is awarded fairly and equitably.

NHS Highland recognises that in order to achieve equal pay for employees doing the same or broadly similar work, work rated as equivalent, or work of equal value, it should operate pay systems which are transparent, based on objective criteria and free from unlawful bias.

In line with the General Duty of the Equality Act 2010, our objectives are to:

Eliminate unfair, unjust or unlawful practices and other discrimination that impact on pay equality

Promote equality of opportunity and the principles of equal pay throughout the workforce.

Promote good relations between people sharing different protected characteristics in the implementation of equal pay

We will:

Review this policy, statement and action points with trade unions and professional organisations as appropriate, every 2 years and provide a formal report within 4 years;

Inform employees as to how pay practices work and how their own pay is determined;

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Provide training and guidance for managers and for those involved in making decisions about pay and benefits and grading decisions;

Examine our existing and future pay practices for all our employees, including part-time workers, those on fixed term contracts or contracts of unspecified duration, and those on pregnancy, maternity or other authorised leave;

Undertake regular monitoring of the impact of our practices in line with the requirements of the Equality Act 2010;

Consider, and where appropriate, undertake a planned programme of equal pay reviews in line with guidance to be developed in partnership with the workforce.

Responsibility for implementing this policy is held by the NHS Highland Chief Executive.

If a member of staff wishes to raise a concern at a formal level within NHS Highland relating to equal pay, the Grievance Procedure is available for their use.

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Gender Pay Gap

The tables below outline the Gender Pay Gap for the Board as a whole and then further broken down across the different terms and conditions in use across the board. The information is presented in three different formats, each defined below.

Mean Pay is a sum of hourly rates divided by the number of hourly rates.

Median Pay is the hourly rate in the middle of all hourly rates in ascending order. For example, 3 is the median of the range 1,2,3,4,5.

Mode Pay is the most common hourly rate.

Gender Pay Gap

Whole Board Male Female Gender Pay Gap

Percentage Digfference

Mean Pay £19.24 £14.56 -£4.68 24.30%Median Pay £15.29 £12.07 -£3.23 21.09%Mode Pay £9.96 £15.29 £5.34

Agenda for Change Male Female Gender Pay Gap


Mean Pay £14.34 £13.88 -£0.47 3.25%Median Pay £12.07 £12.07 £0.00 0.00%Mode Pay £9.96 £15.29 £5.34

Adult Social Care (TUPE) Male Female Gender

Pay GapPercentage Digfference

Mean Pay £14.09 £12.45 -£1.64 11.64%Median Pay £12.28 £10.73 -£1.55 12.62%Mode Pay £19.92 £10.73 -£9.19

Medical and Dental Male Female Gender Pay Gap


Mean Pay £42.65 £38.79 -£3.86 9.06%Median Pay £43.28 £41.66 -£1.62 3.74%Mode Pay £48.59 £43.01 -£5.58

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Senior Management Male Female Gender Pay Gap


Mean Pay £26.76 £28.29 £1.53 -5.73%Median Pay £31.58 £32.49 £0.91 -2.90%Mode Pay £4.30 £4.30 £0.00

The gender pay gap for the board as a whole is significant at negative £5.27 or 28.16%. This is higher than the national average reported in 2015 of 14.8%. 13 The positive Mode pay gap illustrates the relatively high proportion of men in lower paid job families, such as support services. The negative median pay gap of £2.53, when read in conjunction with the Mean pay and Mode pay, effectively shows there are a relatively small number of men in NHS Highland with high levels of pay compared to the rest of the workforce. This can be seen when we look at the Medical and Dental pay gaps.

NHS Highland is committed to moving Adult Social Care staff from their current terms and conditions to Agenda for Change. Opportunities to move other groups of staff will be explored where appropriate.

Pay Gap for Full Time and Part time Employees

The pay gap for full time employees only and part time employees only are noted below. The median pay gaps are relatively small, indeed non-existent for part time employees. However, as noted in the workforce analysis above, the higher proportion of part time women in lower paid job roles has a significant impact on the mean Gender pay gap for female employees with a negative pay gap of £4.67, or 25.2%. The gap is even higher if the mean pay for part time women is compared with the mean pay for full time men, producing a negative pay gap of £5.57.

Full Time Pay Gap


Percentage Difference

Mean Pay £19.46 £15.58 -£3.88 19.92%Median Pay £12.55 £14.55 £2.00 -15.90%Mode Pay £9.96 £15.29 £5.34

13 https://www.closethegap.org.uk/content/gap-statistics/Table3

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Part Time Pay Gap


Percentage Difference

Mean Pay £18.56 £13.89 -£4.67 25.17%Median Pay £10.92 £11.63 £0.71 -6.54%Mode Pay £9.96 £15.29 £5.34

For the first time we are publishing our disability pay gap information. Given the data quality issues noted above we have had to make an assumption that those who have not provided information did not have a disability. We will continue to work to improve the quality of this data.

Disability Declared No Yes Disability

Pay GapPercentage Difference

Mean Pay £15.36 £14.10 -£1.26 8.20%

Median Pay £12.55 £12.31 -£0.24 1.93%

Mode Pay £15.29 £15.29 £0.00

The data shows a negative mean pay gap of £1.26 or 8.2%for those noting a disability. A lesser gap is shown for the Median pay of just £0.24 or 1.93%.

Further qualitative work will be undertaken to understand the reasons for this gap and actions taken to address it accordingly.

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ANNEX 3: SUCCESSION PLANNING

NHS Highland is keen to ensure that the composition of its Board properly covers the full range of interests of its stakeholders, and that membership is open to a true cross section of society. Currently the Board comprises of 20 members and the gender balance is 50:50.

NHS Highland is committed to ensuring that the national challenge for the Boards of all public sector organisations to have a gender balance of 50:50 is maintained.

In order to progress towards a successful strategy in relation to succession planning we will:

Continue to work to assess and define the desired skills, experience and attributes required to promote member diversity

Identify any gaps and design engagement and outreach activity to attract people from a diverse range of groups to the work of the Board

Consider how to nurture those with no previous Board experience to develop the skills required to become a Board member

Engage with some target groups on an on-going basis to develop awareness and understanding of the Board’s work

Deliver development sessions to build capacity for existing Board members to take on leadership roles within the Board’s structure

Work with the Public Appointments Team in Scottish Government to extend the reach of our recruitment to Board positions, using a variety of channels to promote vacancies

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