1. Meeting our Public Sector Equality Duty: our equality objectives

1.1 Implementing the Health and Care Act 2022

2023/24 was a year of change for the NHS with the ongoing implementation of the Health and Care Act 2022, which put integrated care systems (ICSs) on a statutory footing through the creation of integrated care boards (ICBs), and created the new NHS England.*

* The new NHS England was created by the merger with NHS Improvement (made up of the NHS Trust Development Authority and Monitor), NHS Digital and Health Education England.

1.2 This report and Specific Equality Duties’ reporting requirements

Equality objectives provide a strategic focus for change. They help to drive systematic and demonstrable improvements in equality framed by the Equality Act 2010’s 9 protected characteristics and the Public Sector Equality Duty’s 3 equality aims. NHS England is subject to the requirements of the Public Sector Equality Duty (PSED). The general Equality Duty, set out in primary legislation as part of the Equality Act 2010, is supported by Specific Equality Duties (SEDs). The SEDs are secondary legislation in the form of statutory regulations which require the publication of equality information annually and the publication of equality objectives at least every 4 years.

This report meets the requirement to publish equality information for 2023/24. It sets out progress against our 8 equality objectives and targets for 2023/24, and addresses wider statutory reporting requirements under the PSED and SED as at March 2024 (see Appendix 1 of the 2023 review report). It provides an assessment against the key areas set out in last year’s reports by providing:

• a brief update on the changing context within which NHS England is now functioning and what is covered by this report (part 1)
• a summary assessment of our performance against our 8 equality objectives and targets for 2023/24 (part 2)
• broader equality information (part 3)
• the proposed approach to developing the equality objectives and targets for 2025/26 (part 4)
• the equality objectives and targets for 2024/25 (Appendix A)

1.3 NHS England’s workforce data and publication

NHS England is subject to a number of specific equality duties in relation to the publication of workforce information. The regulations require the publication of information relating to NHS England employees who share a protected characteristic; they also require the publication of gender pay gap data. The legacy NHS England published information against protected characteristics such as disability, gender, ethnicity and sexual orientation, drawn from data held in the Electronic Staff Record (ESR) system.

The merger of NHS England, NHS Digital and Health Education England meant we needed to align data from 3 separate ESR systems, create a single ESR system and reflect our new structures within it. This new system was launched in April 2024. We have therefore not been able to produce comparative data by reference to the relevant protected characteristics across the new organisation for 2023/24. We will separately publish the workforce equality information, including on gender pay gap reporting, to meet the requirements of the SEDs and PSED.

1.4 The health inequalities duties

The health inequalities duties are an important part of a separate legislative framework to the Equality Act 2010, the PSED and SEDs. This framework, primarily directed at the NHS, was significantly amended and enhanced by the Health and Care Act 2022 (see Appendix 2 of the 2023 SED Review Report). Under provisions introduced by the Act, NHS England has wide ranging duties, powers and responsibilities in relation to the enhanced health inequalities duties. This report only considers health inequalities where these are directly related to one or more of the 9 protected characteristics and/or address 1 or more of the PSED’s 3 equality aims.

1.5 The equality objectives and targets for 2023/24 and 2024/25

For 2023/24 and 2024/25, NHS England retained and updated the 8 equality objectives (EOs) and targets set for 2022/23. A summary of progress made during 2023/24 is reported against these equality targets:

• equality objective 1 [COVID-19 and recovery]
• equality objective 2 [capability]
• equality objective 3 [information]
• equality objective 4 [internal workforce]
• equality objective 5 [patient access and communication]
• equality objective 6 [system workforce]
• equality objective 7 [integrated care boards]
• equality objective 8 [system landscape]

2. Progress against the 2023/24 equality objectives and targets

2.1 Context

A summary of progress made during 2023/24 for each of the 8 equality objectives and targets is provided here. Where progress towards the target was impacted, a brief explanation has been provided and this has normally resulted in the target being rolled over into 2024/25. Where we are proposing to retire or replace a target in 2024/25, an explanation is provided. The updated targets for 2024/25 are in Appendix A.

2.2 Equality objective 1 [COVID-19 and recovery]

Equality objective 1: To ensure that the equality and health inequality impacts of COVID-19 and key lessons learnt are fully considered and that clear strategies are developed and implemented for the NHS workforce and patients of all ages as the NHS continues to move beyond the recovery phase. To ensure that patient and workforce focused strategies reflect this and make an effective contribution to advancing equality for people of all ages by reference to protected characteristics and to reducing associated health inequalities.

Target 1: To ensure that operational, planning and associated guidance to systems considers how to address and reduce the adverse equality impacts of COVID-19 and provides strategic guidance to the NHS.

Target 2: To work to ensure that key NHS England patient strategies consider the lessons learned from COVID-19 and how to address and reduce the adverse equality impacts of COVID-19.

The 2023/24 priorities and operational planning guidance reconfirmed the ongoing need to recover core services and improve productivity, making progress in delivering the key NHS Long Term Plan ambitions and continuing to transform the NHS for the future. The need to address health inequalities was embedded throughout the guidance.  

The guidance confirmed that system plans should incorporate actions that would continue to reduce inequalities in access, outcomes and experience. The national NHS objectives 2023/24 addressed specific groups of people, for example those living with cancer, those with mental health conditions, people with a learning disability and autistic people, disabled people and other protected characteristic groups (for example maternity), and the prevention of health inequalities.

The 2024/25 priorities and operational planning guidance includes an assessment of progress made during 2023/24 and priorities for 2024/25.

The guidance on developing 2023/24 joint forward plans reflected on how ICBs could further develop their longer-term strategic plans and how key legislative requirements should be addressed in these, including those which impact on equalities and health inequalities. This included the duty to reduce inequalities; the duty to promote integration; the duty to consider the wider effect of decisions; and the quality of service duty.

Target 3: To develop and implement strategies in elective recovery, including for people of all ages, in order to reduce the adverse equality impacts of COVID-19 as the NHS moves further into the recovery phase.

The Elective Recovery Programme established monthly reporting to ensure health inequalities improvement remained a key focus. In February 2022, NHS England published the Delivery plan for tackling the COVID-19 backlog of elective care, setting out how the NHS would recover elective care over the next three years. This plan renewed the commitment to ‘tackling inequality by ensuring the wellbeing offer is accessible to all staff’, including tailored support for staff. It referenced the work being done to increase minority ethnic representation at senior levels across the NHS and to overhaul recruitment and promotion practices. It committed to putting reducing inequalities at the core of recovery plans and performance monitoring. It stated that systems would ‘be expected to analyse their waiting list data by relevant characteristics, including age, deprivation and ethnicity, and by specialty.’ The plan committed to:

• ensuring a ‘fair recovery’ is at the core of our approach
• embedding a focus on health inequalities in how we hold systems to account for delivery
• focusing on equity of access, experience and outcomes for the most deprived 20% of the population and the 5 clinical areas of focus in Core20PLUS5 where we know we can make the greatest difference (maternity, severe mental illness, chronic respiratory disease, cancer and hypertension case-finding)

In May 2023, our letter on elective care set out the priorities, oversight and support for the year ahead as well as a checklist for trust boards to assure themselves across the key priorities. Addressing health inequalities remained a key focus, and the letter stated that it was crucial that the recovery of elective services was inclusive and equitable, with expectations that:

• systems outlined health inequality actions that they planned to implement, including evidence and impact of the interventions, as part of their 2023/24 operational planning returns
• there would be a collective effort to continue to address the recovery of paediatric services. Provider, system and regional-level elective recovery plans were asked to set out actions to accelerate children and young people’s (CYP) recovery and ensure that the elective activity gap between CYP and adults is reduced. To support this, we published a CYP elective recovery toolkit and delivered a series of webinars
• systems continued to recover specialised service activity at an equitable rate to that of less complex procedures, ensuring a balance between high volume and complex patient care requirements

In August 2023, our letter on protecting and expanding elective capacity asked providers to provide assurance against a set of activities to drive outpatient recovery at pace. One element was around developing plans to reduce the rate of missed appointments (DNAs) by March 2024 by engaging with patients to understand and address the root causes and by making it easier for them to change their appointments by replying to their appointment reminders. Providers can use the patient record to more clearly and easily see if there are more missed appointments from certain groups. The Elective Recovery Programme also incorporated health inequalities analysis into our routine reporting.

Progress was made during 2023/24 on all 3 targets even though the context has been challenging. It is therefore recommended that we roll over these targets into 2024/25, and at the same time narrow our reporting under this equality objective to patient focused equalities strategies. Wider NHS workforce equalities matters should be addressed under equality objective 6 as these sit naturally with the NHS Long Term Workforce Plan and the NHS equality, diversity and inclusion (EDI) improvement plan, which both provide the central focus for workforce related EDI strategic planning.

2.3 Equality objective 2 [capability]

Equality objective 2: To improve the capability of NHS England to understand and address the PSED’s legal obligations and the interface with the separate health inequalities duties.

Target 1: To improve the capability of NHS England’s teams to understand and address the PSED’s legal obligations.

We continued to share guidance with NHS England teams, including signposting to a range of guidance, such as the NICE Knowledge Resource, the Health Information Literacy Toolkit and the EHRC Equality Law playlist.

Target 2: To continue to respond to the priorities identified by NHS England’s Board to address patient equalities.

We reviewed NHS England’s Equality and Health Inequalities Impact Assessment (EHIA) process and work was undertaken to improve, streamline and digitise it, with a view to launching a new framework in 2024/25.

The overall assessment is that positive progress was made during 2023/24. We recommend that target 1 is rolled over into 2024/25, and that target 2 is retired for 2024/25, given the overlap between it and reporting under equality objective 1. Board priorities and patient equalities will be reported on under equality objective 1 in 2024/25.

2.4 Equality objective 3 [information]

Equality objective 3: To improve the mapping, quality and extent of equality information to better facilitate compliance with the PSED in relation to patients and NHS service-users of all ages, NHS service delivery, and the NHS workforce.

Target 1: To work with the Department of Health and Social Care (DHSC), Office for National Statistics (ONS), NHS arm’s length bodies, and other government bodies to identify how best to carry forward and oversee the work of the Unified Information Standard for Protected Characteristics (UISPC) Project [2023/24].

DHSC commissioned the UISPC scoping project for the NHS as a whole. Its purpose is to provide recommendations on the collection of improved protected characteristics data on patients and employees, and to enable DHSC and the wider NHS to identify viable options for improving the consistency, detail and quantity of equality data in major NHS information systems and to develop a unified Information Standard/s for this data.

Once implemented, the UISPC should enable NHS organisations to improve care for patients, to further improve how they support their workforce, and to better respond to their legal equalities duties by reference to protected characteristics under the Equality Act 2010.

The UISPC Publication Steering Group (UISPC PSG) has representatives from cross-government agencies, including the NHS Business Services Authority, the Care Quality Commission, the Office for National Statistics, the Government Statistical Service, the Cabinet Office Equality Hub and NHS system partners.

During 2023/24, the UISPC PSG continued to meet and agree how the reports originally produced in 2020 should be updated to incorporate learning from the later stages of the COVID-19 pandemic, the changes to the health and care system, and developments in cross government approaches to monitoring by reference to protected characteristics. Particular consideration was given to developments in relation to relevant harmonised standards published by the Government Statistical Service and the work of the Inclusive Data Taskforce. This review was partially delivered and will be completed during 2024/25.

The overall assessment is that positive progress was made against this target during 2023/24, but that it should be rolled over into 2024/25.

2.5 Equality objective 4 [internal workforce]

Equality objective 4: To improve, by reference to protected characteristics, the recruitment, retention, progression, development, and experience of the people employed by NHS England to enable the organisation to become an inclusive employer of choice.

Target 1: To maintain the 19% aspirational target of ethnic minorities representation at all levels of our organisation  [2023/24 and 2024/25].

Target 2: To continue increasing declaration rates of under-represented groups in our workforce including disabled colleagues [2023/24 and 2024/25].

For the legacy NHS England, the 19% aspirational target was set in March 2020 and has enabled a focus on improving the representation of ethnic minorities staff over the last 4 years. As at 31 March 2024, the representation of Black and ethnic minority staff in the workforce exceeded 19% at all grades between band 2 (the lowest grade) and band 8b. However, at the higher grades (band 8c to Executive Senior Manager/medical leaders), the representation of ethnic minorities staff was less than 19%.

As part of the work to bring NHS England, Health Education England and NHS Digital together as one organisation, a data baselining exercise was undertaken. This compared workforce data on ethnicity, gender, disability and sexual orientation as 4 of the protected characteristics that are captured on ESR. These data will be used for comparative analysis for the new single organisation going forward.

NHS England made progress in the representation of disabled staff, with a representation of 9.7%, an increase of 1.1 % from the previous year – an additional 527 staff.

Diversity targets and improving our declarations of under represented groups

In winter 2023, NHS England’s Executive Group and the People and Remuneration Committee endorsed a new approach to diversity representation targets in the organisation. It was agreed that we would tailor our targets for all protected characteristics to reflect whichever of the following has the highest diversity: the local working population; current internal NHS England workforce; or wider NHS workforce (at a regional level for the seven regions and national level for the 10 national directorates).

In summer 2023, we ran a people census which received 5,008 unique responses out of 18,211 staff – 27% of the organisation. This census also supported the work to reduce the level of unknowns or undeclared data for some staff characteristics when comparing results with the existing data held on ESR, and to increase overall representation figures for disability and lesbian, gay or bisexual staff.

Target 3: To undertake a change programme on our recruitment and promotion, further enabling the organisation to become an employer of choice and a workforce that reflects the communities we serve [2023/24 and 2024/25].

The focus in 2023 was on mitigating inequalities in the selection and appointment process associated with the change programme to create the new, single organisation. This included managers proactively engaging candidates around their accessibility needs or reasonable adjustments and ensuring these were met and hiring managers ensuring that there was diversity in selection panels.

Target 4: To reset our EDI strategy, for the new NHS England, creating opportunities to refresh our targets to ensure they are reflective of our EDI values, local labour markets and accommodating the rapid growth of a merged workforce [2023/24 and 2024/25].

In July 2023, the NHS Executive Group endorsed 7 priority areas which formed our interim EDI strategy for 2023/24. These areas were leadership; accessibility; recruitment; talent management; staff network strategy; safety to speak up; and an employee relations review. 

Target 5: To seek to improve our diversity representation through organisational change [2023/24 and 2024/25].

During the programme to bring together NHS England, Health Education England and NHS Digital – which included reducing our headcount by at least 30% – we saw the following changes in terms of representation:

• ethnic minorities staff increased from 21.1% to 22.9%
• disabled staff increased from 8.6% to 9.7%
• female staff marginally decreased from 69% to 64.7%
• lesbian, gay and bisexual staff remained the same

The overall assessment is that positive progress was made during 2023/24, but that targets 1 to 5 should be rolled over into 2024/25.

2.6 Equality objective 5 [patient access and communication]

Equality objective 5: To improve access and reduce communication barriers experienced by individuals and groups of people of all ages, by reference to protected characteristics, who need NHS services.

Target 1: To publish the updated Accessible Information Standard (AIS).

Target 2: To publish the updated AIS self-assessment framework, e-learning resources and supporting documentation.

During 2023/24, the AIS Programme Board met regularly. Its members include Healthwatch, Care Quality Commission (CQC), DHSC, local authority providers of care, Voluntary, Community and Social Enterprise (VCSE) organisations and other organisations representing people with lived experience.

Alongside, NHS England developed the revised AIS and guidance. These are currently being finalised and will be published this year.

During 2023/24, work was undertaken to explore how an AIS self-assessment framework could be developed. However, this work has been paused and will be revisited once the revised AIS has been published and when we have worked through how we can best support NHS organisations to comply with it

The overall assessment is that considerable progress has been made during 2023/24. We recommend that targets 1 and 2 roll over into 2024/25, and on target 2, work will continue on the self-assessment framework to support colleagues across the NHS to implement the AIS. 

Target 3: To provide a quantitative summary that includes an assessment of accessibility to post COVID services by index of multiple deprivation (IMD) levels of deprivation and ethnicity.

During 2023/24, data on post COVID services activity, population level data, and prevalence trends from the ONS were combined to identify key areas of focus. The learning provided some insights on variations in referral activity and access to post COVID services by reference to deprivation (IMD), ethnicity and geography. Following a review of the data to understand health inequalities across the country, the Long COVID programme worked with partner organisations to identify and agree initiatives that could be piloted to improve awareness and access for specific cohorts of patients.  

During 2023/24, work included a health inequalities focus group and a review of regional and local initiatives shared through clinical networks. A menu of initiatives was developed, based on what had been delivered regionally, supported where possible with evidence of improvement. The programme also worked across key partner organisations, engaging with the NHS VCSE Health and Wellbeing Alliance, the Caribbean and African Health Network, National Voices Lived experience partners and other VCSE organisations. 

Data on the COVID-19 Post-Covid Assessment Service continued to be published during 2023/24 providing information on activity and demographics of patients who had been referred to a Post-Covid (Long Covid) assessment clinic in England. It included data at both national and regional level by reference to age, race and sex as well as socio-economic status and geography.

In December 2023, NHS England published updated guidance for post COVID services which set out the commissioning, service requirements and oversight of these services by ICBs for adults and children and young people. It set out the need for ICBs, when planning and delivering post-COVID services, to consider how they will minimise health inequalities, including for those with a protected characteristic and under-served or marginalised communities, and to allocate a proportion of long COVID services funding to tackling health inequalities.

It placed particular importance on ICBs and services to implement proactive case finding approaches and adapted referral pathways for vulnerable people experiencing long COVID. The guidance points to a need to be aware of diagnostic overshadowing and make reasonable adjustments as required for neuro-divergent groups, or patients with pre-existing physical and mental health conditions or impairments such as visual or hearing loss.

Other highlights during 2023/24 include:

• a new portal to collect and monitor data on equity of access and to enable ongoing research and improvement. The Long COVID Dashboard continues to be accessible to ICBs, to support them to routinely assess and analyse the socio-demographic service activity data against the local socio-demographic composition to understand equity of access
• over 100,000 people, to date, have been seen by specialist post COVID services with 275,000 follow up appointments. A new model of symptom based rehabilitation has been implemented in every ICB. 13 additional hubs for children and young people are available across the country
• digital patient self-management information, which was previously available on the Your COVID Recovery website, had over 20 million views, with content developed alongside lived experience partners to support patients in their recovery

NHS England’s long COVID programme ceased at the end of March 2024 as the future commissioning of post COVID services is now the responsibility of ICBs.

The overall assessment is that significant progress was made during 2023/24. Given the cessation of the NHS England long COVID programme, we recommend that target 3 is retired for NHS England for 2024/25.

Target 4: Through the evaluation of the equity and equality guidance for local maternity systems and the implementation of Local Maternity and Neonatal Systems’ equity and equality action plans, in furtherance of pledge 4, NHS England will measure progress in relation to reducing inequalities in perinatal mortality rates for babies from Black, Asian and mixed ethnic groups and identify how good practice can best be shared and spread.

In 2021, NHS England published equity and equality guidance for local maternity and neonatal systems (LMNS) to ensure that women and babies, regardless of their ethnic background or where they live, get safe, personalised and equitable care. The guidance asked every LMNS to publish an equity and equality action plan in 2023/24 (as set out in the Three year delivery plan for maternity and neonatal services). Every system has produced a plan and by 31 March 2024, 37 of the 42 plans were published. NHS England’s regional teams are working with the remaining LMNSs to ensure their plans are published.  

An evaluation of the equity and equality guidance was commissioned in February 2023 and will likely conclude in March 2025. The final report will include case studies to share good practice.

The 2023/24 priorities and operational planning guidance asked LMNSs to implement their equity and equality action plans. ICBs are asked to oversee delivery of these plans, in line with NHS England’s Operating framework.

NHS England provided funding to LMNSs in 2023/24 to improve maternity and neonatal care focused on key objectives, including to implement their equity and equality action plans. £300,000 was provided to 6 regional teams in November 2023 to implement training programmes to upskill staff and promote more equitable experiences for service users and the workforce. A reverse mentoring and talent programme for the maternity and neonatal workforce was launched in January 2024 and a leadership development programme began in March 2024.

NHS England’s Board, at its meeting of 5 October 2023, received an update on maternity and neonatal services, which noted that work to tackle inequalities includes the implementation of LMNS equity and equality action plans and enhanced midwifery continuity of carer.

How the NHS uses data to measure the impact of work to improve equity

As set out in the Three year delivery plan for maternity and neonatal care technical guidance, published in June 2023, NHS England will examine national data on mortality, pre-term birth, brain injury and experience by ethnicity and deprivation.

The Health inequalities duties statement, published by NHS England in November 2023, helps relevant NHS bodies understand their duties and powers and how they can be exercised. The Statement includes which information on health inequalities should be collected, analysed and published. There are 2 indicators relating to maternity services: pre-term births (before 37 weeks) by ethnicity and deprivation; and the proportion of maternity inpatient settings offering smoking cessation services.

Cultural competence and safety e-learning training has been developed by the NHS in partnership with the Royal College of Midwives and was updated in November 2023, and since then, more than 850 NHS staff and students have completed it. The training aims to support clinicians to gain knowledge and understanding of the issues around culture and health and how this might influence healthcare outcomes.

The NHS Race and Health Observatory (RHO) is an independent expert body which aims to identify and tackle ethnic inequalities in health and care by Black and minority ethnic patients, communities and the workforce in England. In July 2023, the NHS RHO published Review of neonatal assessment and practice in Black, Asian, and minority ethnic newborns. One of the report’s recommendations included “In order to remind learners of the challenges that varying skin tones may introduce when assessing clinical signs, it is important for resuscitation dolls in all Higher Education Institutions and NHS Trusts to include babies with Black or dark skin”. In February 2024, 140 trusts with maternity and neonatal services applied for a set of clinical training aids to support care for women and babies with Black or dark skin. These aids can help support staff to develop the skills to offer appropriate care to all women and babies, whatever their skin tone, so that training better represents the communities we serve. 

In January 2024, the NHS RHO launched the Learning and Action Network, in partnership with the Institute for Healthcare Improvement and the Health Foundation, to work with 9 healthcare systems to improve maternal and neonatal health outcomes.

The Maternity Disparities Taskforce was established in 2022 by Minister for Patient Safety and Primary Care Maria Caulfield, and is now co-chaired by Wendy Olayiwola, NHS England’s National Maternity Lead for Equality. The taskforce brings together experts from across the health system and government departments to tackle disparities in maternal and neonatal outcomes for women from ethnic minorities and those living in the most deprived areas, addressing how wider societal issues impact maternal health. 

The Women and Equalities Select Committee report on Black Maternal Health was published on 18 April 2023. The government’s response published on 30 June 2023 includes the actions the NHS is taking to improve equity and equality.

The overall assessment is that considerable progress has been made during 2023/24, but that target 4 should be rolled over into 2024/25.

2.7 Equality objective 6 [system workforce]

Equality objective 6: To improve, by reference to protected characteristics, the recruitment, retention, progression, development and experience of staff in the NHS workforce.

Target 1: To publish and implement the high impact actions (and their associated success metrics) included in the national NHS Equality, Diversity and Inclusion (EDI) improvement plan, seeking by 2024/25 to develop improvement trajectories for this programme.

The NHS equality, diversity and inclusion improvement plan is an action-orientated plan to improve equality and diversity within the NHS workforce. Coproduced with staff networks and senior leaders, it sets out 6 high impact actions, covering all protected characteristics. The actions have been designed to support NHS organisations to deliver some of the key objectives of the LTWP. The 6 high impact actions are:

• High impact action 1: Chief executives, chairs and board members must have specific and measurable EDI objectives to which they will be individually and collectively accountable
• High impact action 2: Embed fair and inclusive recruitment processes and talent management strategies that target under-representation and lack of diversity
• High impact action 3: Develop and implement an improvement plan to eliminate pay gaps
• High impact action 4: Develop and implement an improvement plan to address health inequalities within the workforce
• High impact action 5: Implement a comprehensive induction, onboarding and development programme for internationally-recruited staff
• High impact action 6: Create an environment that eliminates the conditions in which bullying, discrimination, harassment and physical violence at work occur

Since the launch of the EDI improvement plan:

• webinars and engagement sessions have taken place with ICB leaders, regional HRD networks and professional group forums on each of the high impact actions, and to learn from regulators on what good looks like on workforce outcomes
• the first NHS sexual safety charter has been published, following a national meeting with organisations across healthcare who expressed a renewed commitment to ensuring the NHS is a safe space for staff and patients, where sexual misconduct, violence, harassment or abuse will not be tolerated. A question was also added to the 2023 national NHS Staff Survey to assess the extent of the problem. The interactive results dashboard identifies the questions posed (q17a and q17b)
• a collaborative of ICBs and providers has been established to follow their EDI improvement plan implementation journey and to understand the successes, barriers to implementation, impact etc
• version 2 of the EDI dashboard on the Model Health System has been launched. This allows benchmarking and tracking of 14 of the 17 EDI improvement plan success metrics, including refreshed WRES/ WDES 2023 data, data from the latest NHS staff survey, as well as relevant EDI data from the National Education and Training Survey. The development of a new metric on the diversity of candidates shortlisted, in collaboration with providers and systems, is in progress
• we have started to develop an EDI improvement plan for the primary care sector in collaboration with primary care colleagues
• following the culture review of ambulance trusts published in February 2024, we have started work with the Association of Ambulance Chief Executives to develop a bespoke ambulance sector EDI improvement plan

The overall assessment on target 1 is that positive progress has been made to implement the EDI improvement plan, recognising that 2023/24 was the first year of the implementation of a five-year plan. As the EDI plan has been published, we recommend that ‘publication’ is removed from target 1 but that otherwise this target should roll over into 2024/25.

Target 2: To launch 14 new supported internship programmes during 2023/24 and maintain the remaining 28 programmes launched before 2023/24, to enable NHS organisations to offer supported internship places to young people, aged 18 to 24, targeted at those with a learning disability and/or autistic people, as part of the DFN Project SEARCH programme funded by NHS England.

On 31 March 2021, DFN Project SEARCH was awarded the contract by NHS England and Health Education England to deliver up to 42 new supported internship programmes over three years as part of the NHS commitment to the Learning Disability Employment Programme (LDEP). In 2023/24, the commitment to deliver the final 14 of these programmes was met by NHS England and a number of NHS trusts.

In September 2022/23, the Department for Education (DfE) funded and launched the Internship Works programme as a collaboration between DFN Project SEARCH, the National Development Team for Inclusion, and the British Association for Supported Employment. The programme’s stated aim was to double supported internship provision in England by 2025. This programme drew on the proof of concept provided by the LDEP 42-strong supported internship programme.

By September 2023, the completion of the supported internship programme met the commitment made in the NHS Long Term Plan to significantly increase the number of supported internship programmes across the NHS in England by 2023/24, with half of these leading to work over a five-year term.

As the 42 supported internship programmes were completed by the end of 2023/24, we recommend that target 2 is retired for 2024/25.

Target 3: To implement a framework for monitoring the number of volunteers across the NHS by reference to protected characteristics and any other relevant characteristics.

In June 2023, the NHS Volunteering Task Force published its report and recommendations. This considered a range of ways to take positive steps to advance equality and reduce health inequalities. The report also recommended that NHS England should develop consistent and appropriate measures as part of workforce returns to track the number of NHS volunteers, including: the number of volunteers (mandatory monthly collection); volunteering hours (optional monthly collections); and diversity data – to be included as part of WRES and WDES collections (optional).

During 2023/24, a group of volunteering leads from trusts (data submitters) and ICSs met to agree the scope of the collection and guidance, and to discuss what was required to deliver the targets while reducing the burden on submitting organisations.

Work was undertaken to build the data collection tool (using in house systems) and associated analytics. Technical guidance was drafted and approved by a group of data providers. In February 2024, a submission was made to and approved by the Data Alliance Partnership Board, and it was agreed that collection should begin in 2024/25.  

The overall assessment is that significant progress was made during 2023/24, but that target 3 should be rolled over into 2024/25.

2.8 Equality objective 7 [integrated care boards]

Equality objective 7: To work with integrated care boards (ICBs) to support their compliance with the Equality Act 2010’s Public Sector Equality Duty (PSED) and the associated Specific Equality Duties (SEDs)

Target 1: To work in partnership with Equality and Human Rights Commission (EHRC) to ensure clear guidance is produced for ICBs on the development of equality information and equality objectives.

Target 2: To identify the best ways to support ICBs to meet PSED/SED requirements.

During 2023/24, discussions with the EHRC resulted in the development of a reference document on the health inequalities duties and the PSED, with a view to publication in 2024/25. In addition, NHS England and the EHRC ran two workshops: for ICBs and other NHS organisations focusing on good practice in PSED compliance; and a health regulators’ workshop to inform ICB leaders about what is required under the PSED, and about how CQC, EHRC and NHS England support regulation in relation to equality.

In November 2023, we published our statement on information on health inequalities. This is further to our duty under section 13SA of the National Health Service (NHS) Act 2006 to publish a statement setting out a description of the powers available to relevant NHS bodies to collect, analyse and publish information, and the views of NHS England about how those powers should be exercised in connection with such information.

The overall assessment is that some progress was made during 2023/24 but that targets 1 and 2 should roll over into 2024/25.

2.9 Equality objective 8 [system landscape]

Equality objective 8: To ensure that the equality objectives for NHS England address the relevant statutory functions, duties, powers and responsibilities of NHS England created by the Health and Care Act 2022. [2023/24 and 2024/25]

Target 1: To harmonise the arrangements for PSED and SED compliance across the new NHS England [2023/24 and 2024/25].

The arrangements for PSED and SED compliance have now been harmonised and our new structures are in place. We recommend that target 1 is rolled over into 2024/25 as we continue to progress this work.

Target 2: To review and assess how best to incorporate the Equality Objectives, developed for NHS Digital and Health Education England, into the work to develop revised Equality Objectives for the new NHS England [2023/24 and 2024/25].

The discussions on target 2 focused on the existing equality targets for NHS England. Rather than seeking to incorporate equality objectives from the legacy organisations (NHS Digital and Health Education England), it was felt more appropriate to ensure that proposed equality objectives and targets reflect the remit of the new NHS England.

The overall assessment is that some progress was made against target 2 during 2023/24 but that this target should roll over into 2024/25.

3. Meeting our Public Sector Equality Duty (PSED): our wider equality information

Sections 3.1 to 3.3 provide further information on work undertaken by NHS England in 2023/24. Part 3.4 provides an update on issues identified for future consideration in part 4 of NHS England’s future equality objectives report.

3.1 Patient equalities

During 2023/24, deliverables not already covered in this report included: 

• updating the Equality Delivery System
• undertaking a review of the NHS Equality and Diversity Council
• working with the LGBT+ Sounding Board, made up of 20 volunteers who have lived experience of being LGBT+ and knowledge of the health inequalities faced by their communities
• providing guidance and advice to support our staff to deliver our equalities and health inequalities legal duties.

3.2 Healthcare inequalities improvement programme

The national healthcare inequalities improvement programme delivered a range of work in 2023/24 to reduce health inequalities. In July 2023, the annual report on NHS England’s work on healthcare inequalities and the NHS Race and Health Observatory provided examples of work delivered to improve access, experience and outcomes for all.

The annual report detailed the work to address the health inequalities related to the protected characteristic of race. This included work across maternity and neonatal health, mental health, sickle cell disease, genomics, the workforce, and COVID-19, making recommendations for policy and practice.

Frameworks published in 2023/24 included inclusive digital healthcare: a framework for NHS action on digital inclusion and a national framework for NHS action on inclusion health, to support every integrated care system to shape and take their next steps in improving access, experience and outcomes for people in inclusion health groups.

3.3 Workforce equalities

3.3.1 NHS Long Term Workforce Plan and NHS equality, diversity and inclusion improvement plan

A central focus during 2023/24 was the development and launch of the NHS Long Term Workforce Plan, and the NHS equality, diversity and inclusion improvement plan, which was a key target for 2023/24.

3.3.2 The Workforce Disability Equality Standard

The Workforce Disability Equality Standard (WDES) is a mandated standard that provides a strategic direction for disability equality. A WDES national data collection takes place annually. Trusts collect, report and publish data against a collection of 10 metrics that compare the workplace experiences of disabled and non-disabled staff as at 31 March of each year. The WDES is mandated for NHS trusts and NHS foundation trusts and, on a voluntary basis, covers arm’s-length bodies. The purpose of the WDES is to identify and close the gaps in experience between disabled and non-disabled staff. In March 2024, NHS England published Workforce Disability Equality Standard: 2023 data analysis report for NHS trusts.

The report provided the 5-year trend since the first report on 2019 data. In addition to the detailed quantitative, qualitative and statistical analysis provided, the report also included a spotlight on the work of the top 10 percent of trusts for each metric, to demonstrate the art of the possible.

The report shows that disabled representation on NHS boards increased to 5.7% in 2023, an increase of 1.1% from 2022. Disability declaration rates by NHS staff have significantly improved, up by 19.9% due to improved engagement by NHS trusts, and board members declaring a disability has risen from 2.1 % in 2019 to 5.7%. The increase comes following the establishment of the Disabled NHS Directors Network, which aims to identify and promote best practice in supporting and recruiting disabled staff.

3.3.3 The Workforce Race Equality Standard

The 2023 Workforce Race Equality Standard (WRES) report was published in March 2024. The eighth publication since the WRES was mandated, the report covers 9 indicators and enables organisations to compare their performance with others in their region and those providing similar services, to encourage improvement by learning and sharing good practice.

The report provides a snapshot of where NHS trusts and foundation trusts were in the reporting period on addressing race inequalities. It shows evidence of ongoing and sustained improvement since 2016 across the indicators that measure representation, shortlisting to appointment and continuous development, including that ethnic minority representation at very senior manager (VSM) pay bands has risen by more than half (61.7%) since 2018, from 201 to 325 in 2023 – the highest on record, while ethnic minority representation at executive board level has also increased to more than one in ten of executive roles (11%) – up from 9% in 2021.

The report also shows there is more work to be done, with white shortlisted job applicants 1.59 times more likely to be appointed from shortlisting than ethnic minority shortlisted applicants – a decline from 1.53 in 2022.

3.4 Key considerations from the 2023 future equality objectives report

NHS England’s 2023/24 future objectives report identified a number of areas for consideration in 2023/24. A summary of actions taken during 2023/24 is reported here.

3.4.1 Black maternal health and wider inequalities

The Three Year Delivery Plan for Maternity and Neonatal Services includes 7 key asks of Local Maternity and Neonatal Systems (LMNS) in relation to equity and equality. An update on each of these is in the following table, and additional information is provided in the assessment of progress against equality objective 5, target 2.

The Three year delivery plan also asked local systems to implement the updated Saving babies lives care bundle which was published in May 2023.  Every element of the care bundle includes actions to improve equity.

3.4.2 Community languages

In April 2023, the former Healthcare Safety Investigation Branch (now Health Services Safety Investigation Body) issued a report, Clinical investigation booking systems failures: written communications in community languages. It highlighted a language gap across the NHS in letters about crucial scans and tests. The report set out a series of safety observations and recommendations, including to clarify the role and functions of national organisations in improving health inequalities and developing a standard for healthcare providers on supplying written appointment information in languages other than English.

To identify the most effective policy levers or interventions to address issues and improve community languages, translation and interpretation (CLTI) services, NHS England made a commitment to complete a strategic review in 2023/24. The review considered the breadth and complexity of issues across the patient pathway and set out an options appraisal of potential interventions. Addressing issues with written appointment information is a core component of the review. The review is also looking at how to best facilitate improvements to CLTI services and help ensure they meet the needs of communities and support equitable access, experience, and outcomes for all. This review is therefore designed to address health inequalities, equalities and patient safety.

In November 2023, NHS England published a framework for NHS action on digital inclusion and started to develop further resources to support practical action. The report identified that eleven million adults (21% of the population of the UK) lack basic digital skills, or do not use digital technology at all. They are likely to be older, have lower levels of qualifications, and be in poorer health than the rest of the population. The report identified older age as the strongest single predictor of reduced internet access and use among adults and that digital services must be designed to alleviate healthcare inequalities rather than exacerbate them. The report recommended that reducing health inequalities and improving digital inclusion have due focus in wider inclusive user design and delivery for all digital products and services.   

It is also important to note that Service Condition 13.2 of the NHS Standard Contract has been in place for a number of years and states that providers: ‘must provide appropriate assistance and make reasonable adjustments for Service Users, Carers and Legal Guardians who do not speak, read or write English or who have communication difficulties (including hearing, oral or learning impairments).’ Providers also ‘must carry out an annual audit of its compliance with this obligation and must demonstrate at Review Meetings the extent to which Service improvements have been made as a result.’

3.4.3 EHRC: detention (inappropriate) of people with a learning disability and autism

The EHRC’s letter to ICB chief executives in February 2023 highlighted 3 key EHRC priorities over the coming two years, including to tackle the inappropriate detention of people with a learning disability and autism*.

* As defined by the EHRC: By “inappropriate detention” the EHRC is referring to “situations where someone does not need inpatient care but is detained due to lack of community provision, is subject to physical restraint/long-term segregation, and/or suffers from the absence of an effective mechanism to challenge prolonged detention.”

The NHS Long Term Plan committed to increased investment in intensive, crisis and forensic community support to enable people with a learning disability and autistic people to receive personalised care in the community and to reduce admissions to mental health inpatient services and support timely discharge. NHS England has worked with local systems to help them to understand what else needs to be done to deliver this commitment, and we invested £121 million in 2023/24 to support local systems to continue to develop and deliver these services. 

NHS England worked alongside the Local Government Association and Association of Directors of Adult Social Services to develop a set of joint guiding principles, published in May 2023, for integrated care systems. These set out how partners in local systems can best work together to improve the lives and outcomes of people with a learning disability and autistic people of all ages. Our letter, in January 2024, established the five key elements to support timely discharge from mental health hospitals to local health systems, to help them to support people with a learning disability and autistic people to leave hospital as soon as they are ready.  

Good community services and housing support are essential to improve the health and wellbeing of autistic people and people with a learning disability. Brick by Brick resources have been developed to support mental health hospital-to-home discharge planning for autistic people and people with a learning disability so that housing is planned and sourced as early as possible in a discharge process. Additionally, we built on Building the right home guidance which outlined how a range of housing options can be provided to support people to leave mental health hospitals, or to prevent them needing admission to one. In February 2024, Building the right home: NHS housing capital guidance was published. This is designed to ‘help integrated care boards, local authorities and support, care and housing providers to access capital grant funding to develop housing that will play a key role in reducing the number of autistic people and people with a learning disability in a mental health hospital setting, as set out in the NHS Long Term Plan.’.

We have supported the development of community-based support for children and young people with a learning disability and autistic children and young people to reduce reliance on mental health inpatient settings. There are now key worker services for children and young people in every part of the country with over 2,600 children currently being supported. The Autism in Schools project has been successfully expanded (over 300 schools) and a new joint project established between NHS England, Department for Education, and Department of Health and Social Care – the Partnerships for Inclusion of Neurodiversity in Schools (PINS) project – open to all 42 ICBs. This project will support whole school improvement in up to 1600 primary schools.  

We published guidance to support local health commissioners to commission good quality mental health inpatient care and community care, including:

• Acute inpatient mental health care for adults and older adults
• A national framework to deliver improved outcomes in all-age autism assessment pathways: guidance for integrated care boards
• Commissioning framework for mental health inpatient services
• Dynamic support registers and Care (Education) and Treatment Review code of practice

3.4.4 EHRC: detention of ethnic minority people under the Mental Health Act 1983

The EHRC’s letter to ICB chief executives included the need to tackle disproportionate rates of detention of ethnic minority people under the Mental Health Act 1983.

The Patient and carer race equality framework (PCREF) was published in October 2023. This drew on work undertaken between 2020 and 2023 by NHS England and 4 mental health trusts to pilot the framework across the country. Alongside, NHS England’s consultation on the NHS Standard Contract for 2024/25 included a proposal to add a new mandatory clause on the PCREF to Service Condition 13 on Equity of Access, Equality and Non-Discrimination. The new Service Condition (SC13.9) was incorporated in the final NHS Standard Contract for 2024/25 and it requires all mental health providers to have implemented the PCREF by March 2025.

All mental health providers, supported by their ICBs, have been required to monitor and publish the PCREF metrics which include ‘Tackling disproportionate rates of detention of ethnic minority people under the Mental Health Act 1983’.

The priorities and operational planning guidance 2024/25 set out a series of requirements in relation to mental health and associated services. Under part 2H, the guidance specifically requires the implementation of the PCREF by the end of 2024/25, and for mental health providers to establish the governance structure and reporting metrics to monitor the access, experience, and outcomes of ethnic minority groups, and to build organisational competencies.

3.4.5 Education, training and capability

The engagement report, published in June 2023, talked about further work required to build NHS staff’s understanding across a number of equalities area. The future objectives report (4.2) noted that during 2023/24 consideration would be given to whether further improvements could be made as part of implementing the NHS EDI improvement plan, and our assessment is that the plan does provide a vehicle for this.

3.4.6 EHRC: Experience of low paid ethnic minority staff

The EHRC’s letter to ICB chief executives included the need to consider the experience of low paid ethnic minority staff. The EHRC drew attention to its report – experiences from health and social care: the treatment of lower-paid ethnic minority workers – which was published alongside low-paid ethnic minority workers in health and social care during COVID-19: A rapid review in June 2022.

NHS Digital published experimental statistics analysing pay by reference to ethnicity for a number of years. The last round of data – NHS Staff Earnings Estimates, June 2023, Provisional Statistics (including supplementary analysis on pay by ethnicity) – was published in September 2023.

The EDI improvement plan’s High Impact Action 3 is to ‘Develop and implement an improvement plan to eliminate pay gaps.’ As an inclusive employer, the NHS has been asked to take steps to address gender, ethnicity and disability pay gaps.

4. Developing the next round of equality objectives and targets

4.1 Extending the current 8 equality objectives into 2025/26

Eight equality objectives and associated targets were set for 2021/22, 2022/23 and 2023/24. As the SEDs require specific and measurable equality objectives to be set at least every 4 years, we propose carrying over the existing 8 equality objectives into 2025/26.

4.2 Reviewing the targets set for 2024/25 and setting targets for 2025/26

NHS England has a statutory obligation to publish equality information annually. The next publication date is May 2025. It is proposed that the targets set for 2024/25 should run until June 2025 unless a decision is made by the Board, designated committee or delegated group to retire any of the targets at an earlier date. It is proposed that the Board receives an SED Review Report in May 2025 and that should consider progress against the equality targets set for 2024/25 and targets to be set for 2025/26.

Appendix A: NHS England’s equality objectives and updated targets for 2024/25 and 2025/26

These equality targets have been updated in light of the information in this report. No changes have been proposed to the 8 overall equality objectives. Some targets have been retired but most have been rolled over for 2024/25 and 2025/26.

Equality objective 1 [COVID-19 and recovery] 

To ensure that the equality and health inequality impacts of COVID-19 and key lessons learnt are fully considered and that clear strategies are developed and implemented for the NHS workforce and patients of all ages as the NHS continues to move beyond the recovery phase. To ensure that patient and workforce focused strategies reflect this and make an effective contribution to advancing equality for people of all ages by reference to protected characteristics and to reducing associated health inequalities. 

Target 1: To ensure that operational, planning and associated guidance to systems considers how to address and reduce the adverse equality impacts of COVID-19 and provides strategic guidance to the NHS.

Target 2: To work to ensure that key NHS England patient strategies consider the lessons learned from COVID-19 and how to address and reduce the adverse equality impacts of COVID-19.

Target 3: To develop and implement strategies in elective recovery, including for people of all ages, in order to reduce the adverse equality impacts of COVID-19 as the NHS moves further into the recovery phase.

Equality objective 2 [capability] 

To improve the capability of NHS England to understand and address the PSED’s legal obligations and the interface with the separate health inequalities duties.  

Target 1: To improve the capability of NHS England’s teams to understand and address the PSED’s legal obligations.

Equality objective 3 [information] 

To improve the mapping, quality and extent of equality information to better facilitate compliance with the PSED in relation to patients and NHS service-users of all ages, NHS service delivery, and the NHS workforce.  

Target 1: To work with the DHSC, ONS, NHS arm’s length bodies, and other government bodies to identify how best to carry forward and oversee the work of the UISPC Project.

Equality objective 4 [internal workforce] 

To improve, by reference to protected characteristics, the recruitment, retention, progression, development, and experience of the people employed by NHS England to enable the organisation to become an inclusive employer of choice. 

Target 1: To maintain the 19% aspirational target of ethnic minorities representation at all levels of our organisation.

Target 2: To continue increasing declaration rates of under-represented groups in our workforce including disabled colleagues.

Target 3: To undertake a change programme on our recruitment and promotion, further enabling the organisation to become an employer of choice and a workforce that reflects the communities we serve.

Target 4: To reset our EDI strategy, for the new NHS England, creating opportunities to refresh our targets to ensure they are reflective of our EDI values, local labour markets and accommodating the rapid growth of a merged workforce.

Target 5: To seek to improve our diversity representation through organisational change.

Equality objective 5 [patient access and communication] 

To improve access and reduce communication barriers experienced by individuals and groups of people of all ages, by reference to protected characteristics, who need NHS services.  

Target 1: To publish the updated Accessible Information Standard (AIS).

Target 2: To publish the updated AIS self-assessment framework, e-learning resources and supporting documentation.

Target 3: Through the evaluation of the Equity and equality guidance and implementation of Local Maternity and Neonatal Systems (LMNS) equity and equality action plans, in furtherance of pledge 4, NHS England will measure progress in relation to reducing inequalities in perinatal mortality rates for babies from Black, Asian and mixed ethnic groups and identify how good practice can best be shared and spread.

Equality objective 6 [system workforce] 

To improve, by reference to protected characteristics, the recruitment, retention, progression, development and experience of staff in the NHS workforce. 

Target 1: To implement the high impact actions (and their associated success metrics) included in the national NHS Equality, Diversity and Inclusion (EDI) improvement plan seeking by 2024/25 to develop improvement trajectories for this programme.

Target 2: To implement a framework for monitoring the number of volunteers across the NHS by reference to protected characteristics and any other relevant characteristics.

Equality objective 7 [integrated care boards] 

To work with Integrated Care Boards (ICBs) to support their compliance with the Equality Act 2010’s Public Sector Equality Duty (PSED) and the associated Specific Equality Duties (SEDs).  

Target 1: To work in partnership with Equality and Human Rights Commission (EHRC) to ensure clear guidance is produced for ICBs on the development of equality information and equality objectives.

Target 2: To identify the best ways to support ICBs to meet PSED/SED requirements.

Equality objective 8 [system landscape] 

To ensure that the equality objectives for NHS England address the relevant statutory functions, duties, powers and responsibilities of NHS England created by the Health and Care Act 2022.

Target 1: To harmonise the arrangements for PSED and SED compliance across the new NHS England.

Target 2: To review and assess how best to incorporate the Equality Objectives, developed for NHS Digital and Health Education England, into the work to develop revised Equality Objectives for the new NHS England.