NHSScotland conduct policy: equality impact assessment

NHSScotland Conduct Policy : Equality Impact Assessment Results

Title of Policy

NHSScotland Conduct Policy

Summary of aims and desired outcomes of Policy

The aim of the policy is to provide a process to ensure that concerns about standards of conduct, inappropriate behaviour or wilful misconduct are managed in a fair, consistent and timely manner.

This is a refresh of the previous Management of Employee Conduct PIN Policy (2012).

Directorate

Health Workforce

1. Executive summary

The Equality Act 2010 places a duty (known as the Public Sector Equality Duty, or PSED) on public authorities to have due regard to the need to eliminate discrimination, advance equality of opportunity, and promote good relations between people who share a protected characteristic and those who do not. The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 (Regulation 5) require public authorities to assess and review policies and practices against the three needs of the PSED.

The Scottish Government has undertaken national equality impact assessments (EQIAs) as part of the policy development process to refresh the extant NHSScotland Partnership Information Network (PIN) workforce policies. This EQIA Results Report provides a summary of the key findings from the EQIA Record prepared for each workforce policy.

The EQIA evaluates how a policy may affect different segments of the population both positively and negatively. If adverse effects are identified, efforts have been made to reduce or remove them. However, the focus is not solely on negating negative impacts, as there is also a proactive duty to promote equality. The development of the EQIA has been guided by equality legislation and addresses the protected characteristics of age, disability, gender reassignment, sex, pregnancy and maternity, race, religion or belief, and sexual orientation.

The NHSScotland Conduct Policy has been equality impact assessed, and it has been determined that there are no barriers to any of the protected characteristics. The policy is expected to positively impact on eliminating unlawful discrimination, harassment and victimisation and advance equality of opportunity across all protected characteristics. The policy has no negative impact in promotinggood relations between people who share a protected characteristic and those who do not. The key findings section below provides a summary of the policy's impact on individuals with protected characteristics.

Scottish Government is committed to actively considering equality impacts during the implementation of the NHSScotland workforce policies. This EQIA will be subject to further review and revision to ensure that any negative impacts, whether direct or indirect, on individuals with protected characteristics are addressed and mitigated.

2. Background

The 'Once for Scotland' Workforce Policies Programme was commissioned by the Scottish Workforce and Staff Governance Committee to review and transform existing workforce policies [previously known as Partnership Information Network (PIN) Policies] in line with the following vision:

'Once for Scotland Workforce policies will promote NHSScotland as a modern, exemplar employer; showcasing our core values, and promoting consistent employment policy and practice that supports the implementation of the Staff Governance Standard and effective recruitment and retention.'

The refreshed NHSScotland Conduct Policy reflects feedback from regional engagement events pre- and mid-policy development and a formal consultation with a broad range of stakeholders. An invite to participate in the public consultation was sent to a wide range of stakeholders across NHS Boards and their staff networks, trade unions and professional organisations, and external protected characteristics equalities groups. Additional advice was sought from subject matter experts.

The policy, and associated supporting documents, set the standard for employment practice for all NHS Boards in Scotland, and are accessible through the NHSScotland Workforce Policies website. The website was developed through extensive user testing and is compliant to Web Content Accessibility Guidelines (WCAG) 2.1 Level AA standard.

The policy and supporting documents are adopted by NHS Boards, at a local level, to ensure a fair and consistent approach to the processes relating to managing employee conduct in the workplace.

The fair and consistent application of policy and treatment of staff working for the NHS in Scotland is the key driver for the move to a single policy position.

NHSScotland workforce policies support the requirements of the Staff Governance Standard (2012), in relation to the following five strands:

• well informed
• appropriately trained and developed
• involved in decisions
• treated fairly and consistently
• provided with a safe working environment

3. The Scope of the EQIA

On the basis that the policy and associated supporting documents set the standard for employment practice for all NHS Boards in Scotland to follow, a full EQIA was deemed appropriate.

The EQIA is based on a thorough analysis of existing evidence and data. Its purpose is to identify and understand the potential impacts that the NHSScotland Conduct Policy may have on individuals with protected characteristics, as defined in the Equality Act 2010.

Specifically, the EQIA assesses the impacts of applying the revised policy against the needs relevant to a public authority's obligations under the Public Sector Equality Duty. The needs are to:

• eliminate discrimination, harassment and victimisation
• advance equality of opportunity
• foster good relations

In addition to the stakeholder engagement noted above, evidence was gathered from a broad range of sources. Data was reviewed from the following national data sets:

• NHSScotland Workforce data
• The Scottish Household Survey
• Labour market statistics

4. Key Findings

The EQIA has highlighted areas with potential impacts on different groups and opportunities for promoting equality.

The NHSScotland Conduct Policy is expected to have a positive effect in eliminating unlawful discrimination, harassment and victimisation across all protected characteristics. The Conduct Policy:

• states that acts of gross misconduct are so serious in themselves, or have such serious consequences, that dismissal is the appropriate sanction. Examples of gross misconduct include wilful disregard of equality and diversity policies and significant or persistent bullying and harassment of a fellow employee or any other person.
• is accessible through a publicly available website, supporting staff with safe and confidential access to information about the conduct process.
• employee guide makes clear that where an employee perceives they are being discriminated against due to their protected characteristic, a grievance or bullying and harassment complaint may be raised. The conduct process may be paused where this is appropriate to deal with the grievance or complaint.
• highlights the right to be represented applies at each stage of the process which ensures policies are applied appropriately.
• highlights the right of appeal which offers an opportunity to address any flaws in the process or decision making.
• requires the disciplinary hearing panel to consist of three individuals who have no prior involvement in the process. This further supports the elimination of discrimination.
• directs to advocacy support and highlights that policies and supporting information may be made available, in full or summary form, in alternative formats and community languages.
• adopts non-gendered terminology with role specific terms such as manager, employee, staff used. Pronouns they, their, them have been used throughout.
• reinforces compliance with the Equality Act (2010) and the Principles and Values | NHS Scotland.
• is written to fulfil legislative requirements and comply with statutory responsibilities.

The NHSScotland Conduct Policy has a positive impact in advancing equality of opportunity across all protected characteristics. The Conduct Policy:

• promotes equity of access within the Principles and Values standard section which underpins all policies and supporting documents. This section highlights considerations required to be given to communications with employees who may have additional needs, and where these impact on their ability to understand or express themselves. For example, learning difficulties, physical disabilities, or mental health issues.
• recognises that some employees, may at times, have difficulty expressing themselves verbally or on paper. For example, those whose first language is not English or those with literacy issues may need additional support to access or participate fully and equitably in workforce policy processes.
• supports staff across the workforce to engage with policy in a meaningful way by simplifying content and making policy and documents publicly available.
• is accessible through a purpose built NHSScotland Workforce Policies website. The website scores high on the System Usability Scale (universal usability scoring system). This may particularly support older staff or staff with certain disabilities, advancing equality of opportunity through accessibility.
• multiple usability studies were carried out. Insights from user testing have been used to improve the experience for all staff. The following may particularly support older staff or staff with certain disabilities, advancing equality of opportunity through accessibility:
  • screen can be zoomed beyond 300%
  • used an 18px font size as standard, making the starting size for fonts more readable.
  • alternative formats page where users can request content in a format that suits their needs.
  • a site map, that can help some people find content more easily.
  • supporting documents have an HTML version that makes the content more accessible than they would be in PDF or other file formats.
  • links all use meaningful text which can be read and understood out of context by screen reader users.
  • headings follow a sematic structure allowing screen reader users to easily scan and understand the content structure.
  • colour contrast of all text is compliant to WCAG 2.1 Level AA standards.
  • meaningful text alternative created for the visual flowcharts. This is linked to before the visual flowcharts to support screen reader users.
  • development of a style guide for policy writing which focuses on improving readability for a range of users. Reducing sentence length, best use of grammar, providing meaningful website links. advancing equality of opportunity through accessibility.
• advocates a person-centred approach in the application of all NHSScotland Workforce policies. This is demonstrated across the policy and supporting documents.

The NHSScotland Conduct Policy has no negative impact in promoting good relations between people who share a protected characteristic and those who do not. The policy applies to all employees and workers. Managers are encouraged to take a person-centred approach.

The website was developed through extensive user testing and is compliant to Web Content Accessibility Guidelines (WCAG) 2.1 Level AA standard. However, in terms of access to the policy, it was identified that some staff may struggle with technology or do not have access or experience of using IT equipment and could be disadvantaged. This may be more likely in older age groups.

The following actions have been taken to minimise any negative impact:

• policies and supporting documents have been created as downloadable documents which can be printed and shared in hard copy.
• upon initiating a workforce policy, managers are required to formally write to the employee informing them of this. Within this, managers are asked to include a hard copy of the policy, flowchart and any other relevant supporting documents.
• downloadable copies of the policy and supporting documents include a references section. This details in full any hyperlinks contained within the document to support those accessing hard copies and provide signposting.

Scottish Government will continue to monitor and review this EQIA to ensure ongoing assessment of potential impacts on people with protected characteristics.

5. Recommendations and conclusion

NHSScotland's commitment to eliminating unlawful discrimination, harassment, victimisation and less favourable treatment is central to the principles and values that underpin these policies.

NHSScotland workforce policies should be applied fairly and consistently to any employee or worker regardless of:

• protected characteristics (age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership or pregnancy and maternity)
• personal characteristics such as trans identities including non-binary, weight, social status
• offender status
• membership or non-membership of a trade union
• contractual status - part-time or fixed-term

The EQIA process did not identify indirect or direct discrimination through the policy intentions of the NHSScotland Conduct Policy.

It is anticipated that the policy will positively impact on eliminating unlawful discrimination, harassment and victimisation and advance equality of opportunity across all protected characteristics. The NHSScotland Conduct Policy has no negative impact in promotinggood relations between people who share a protected characteristic and those who do not. There is no evidence of negative impacts on people with protected characteristics.

The EQIA will be kept under review and updated based on new data, evidence or policy revision. Monitoring and review of this policy is an on-going process, involving iterative discussions with NHSScotland partnership groups. It will form part of the monitoring and review of Board's achievement of the Staff Governance Standard (2012) carried out through the Staff Governance Monitoring Framework. Further engagement with protected characteristic groups through staff networks and forums will form part of the ongoing review to ensure that the conclusions reached in the EQIA meet the needs of these groups.

Analytics from the website will allow collation of data related to use and accessibility of the policy, in addition to workforce data gathered through national datasets.