Equality delivery system
The equality delivery system (EDS) is a framework to improve the services we provide to patients and the working environment for staff. It helps ensure that care is fair, accessible, and responsive to the diverse needs of local communities.
It supports NHS organisations to meet legal duties under the Equality Act 2010 by focusing on three key areas:
- Services for patients – ensuring equitable access, safety, and positive experiences for all.
- Workforce health and wellbeing – promoting a supportive, inclusive workplace free from discrimination.
- Inclusive leadership – encouraging leaders to embed equality into decision-making and governance.
In doing so we seek to:
- Eliminate discrimination, harassment, and victimisation
- Advance equality of opportunity between people who share a protected characteristic and those who do not
- Foster good relations between different groups.
To meet these duties, we are required to:
- Publish equality information annually, showing how we are meeting the duty
- Set and publish equality objectives at least every four years, which must be specific, measurable, and aligned with organisational priorities
- Monitor progress and engage with staff, patients, and communities to ensure objectives reflect real needs and promote transparency
Equality objectives
Equality objectives help us demonstrate how we are meeting our statutory duties.
The purpose of the equality objectives is to help us make a real difference to some of the most pressing issues facing the protected groups that we provide services for and employ.
They will also help us demonstrate how we are meeting our statutory duties.
We have worked with our third sector and public sector partners and used what we have learnt from equality information, census and patient data to help identify our equality goals for the next four years.
We will continue to monitor progress of the equality objectives and how risks to delivery will be identified and addressed.
Equality Delivery System – 2023/2024 ReportEquality delivery system – patient objectives 2025 – 2029
| Outcome | Objective | Action | Completion date |
| 1A: Patients (service users) have required levels of access to the service | Support patients who face language barriers to access health services | – Pilot CardMedic in Maternity services – Language empire – staff training – Promotion of English Unlocked online training – Promotion of Deaflink online training – Continue partnership working with Deaflink and regional trusts on supporting BSL users and Health Navigator Pilot | April 2026 |
| 1A: Patients (service users) have required levels of access to the service | Support the positive experience of unpaid and paid carers | – Continue partnership working with Newcastle Carers Pilot Triangle of Care in preassessment – Update protocol and policy for paid carers – Explore the use of carer lanyards and carer identification cards | June 2026 |
| 1A: Patients (service users) have required levels of access to the service | Improve access to services for patients with reasonable adjustments | – Analyse feedback and implement any improvements identified by the Quality Checker reports in Emergency Department, Paediatric ED, Antenatal, Urology – ward 1 and 2, Pharmacy, Outpatients (RVI), Radiology (RVI), Plaster room, Endoscopy – Sighted guide training which has been co-produced by a patient with lived experience and the charity Guide Dogs. Three sessions will be delivered which are open for all staff members and a bespoke Ophthalmology session – Explore the opportunity of creating communication support boxes for patients in collaboration with Northumbria – Support the health inequalities strategy aim to identify and implement Reasonable Adjustments for 100% of patients with additional needs | August 2026 December 2028 |
| 1A: Patients (service users) have required levels of access to the service | Support patients experiencing health inequalities to access services | – Support the Health Inequalities strategy objective to reduce DNAs/ WNBs by 3% among patients from IMD 1 and 2, and ethnically minoritised persons – Understand the experience of children waiting for dentist appointments and adults on orthopaedic waiting lists -Support the Health Inequalities strategy objective that by December 2026, 10% of patient letters will meet the Accessible Information Standard, and a reading age of 9 years. (100% by December 2029) | December 2027 December 2026 |
| 1B: Individual patients (service users) health needs are met | Support staff caring for patients and visitors from protected characteristic groups, including disabled, LGBT and religious groups | – Develop and implement the email correspondence policy – Conduct an audit of the EPR to better understand process of flags for patients who require reasonable adjustments under the Accessible Information Standard – Work with medical records to explore how to improve the administrative process for patients who want to update their gender and pronouns on their medical records – Positive partnership working with chaplaincy team and local community organisations to improve the experience of patients from a global majority background and religious groups | December 2026 |
| 1C: When patients (service users) use the service, they are free from harm | Develop improvement ideas in response to feedback from diverse backgrounds | – Support ongoing work within maternity to improve experience for global majority patients and those who do not speak English – Explore the feedback received about disparity in receiving of pain medication – Continue to promote the HIV stigma reporting portal and the HIV Confident online staff training – Review interpretation resources, training, and staff awareness, particularly in relation to unplanned admissions | December 2026 |
| 1C: When patients (service users) use the service, they are free from harm | Develop improvement ideas in response to feedback from diverse backgrounds Involve and engage Patient Safety Partners in line with the requirements of the Patient Safety Incident Reporting Framework | Support the Health Inequalities Strategy objective to measure clinical outcomes, such as safety incidents, among 100% ethnically minoritised persons; people with learning or physical disabilities; and autistic people; and co-design quality and safety improvement programmes with affected patient groups – Provide training and ongoing support for newly recruited – Patient Safety Partners Identify opportunities within clinical boards for Patient Safety Partners to be involved | December 2028 |
| 1D: Patients (service users) report positive experiences of the service | Obtain more feedback from a diverse range of patients to ensure feedback is representative of the communities that we support | – Large scale measurement of patient experience broken down by protected characteristic – Analyse compliments received by protected characteristics and celebrate success through case stories | April 2026 |
