The Leeds Teaching Hospitals NHS Trust

Equality Delivery System

NHS Equality Delivery System

The EDS serves the purpose of helping NHS organisations review and improve their performance for people with protected characteristics and help deliver on the PSED. The EDS sets out the following goals:

  1. Better health outcomes including services commissioned, procured, designed and, delivered to meet the health needs of local communities.
  2. Improved patient access and experience including patients being informed and supported to be involved in decisions and reporting positive experiences.
  3. A representative and supported workforce including fair recruitment and selection processes and flexible working options.
  4. Inclusive leadership including papers that come before the Board and other major committees identifying equality-related impacts.

In 2017 the Leeds EDS process was revised in collaboration with our key stakeholders in the voluntary community sector to bring focus to measurable impact on specific protected groups for real reductions in inequalities. To facilitate the shift in focus, the process moved from an annual cycle to one of three years, as set out overleaf in Table 1.

Table 1: NHS Equality Delivery System Process 2018 to 2020

Year NHS EDS Goals
2018 1. Better Health Outcomes For All
2019 2. Improved Patient Access and Experience
2020 3. Empowered, Engaged all Well-supported Staff
2020 4. Inclusive Leadership at All Levels

Following a pilot of the revised Leeds EDS process in 2018 with Goal 1, it was decided that assessment of each Goal would involve the following:

  • Workshop - To be held six months in advance of the assessment to provide an opportunity for meaningful discussion between Leeds NHS organisations and key stakeholders on the gaps and areas for improvement for an assessment in December.
  • Assessment - To involve the presentation of information from each NHS organisation on the areas of focus agreed at the workshop. To conclude with a decision on the measurable impact to be assessed against in 12 months and each year after in the three year cycle.

Due to the impact of COVID on all organisations involved in the Leeds EDS process, only the assessment for Goals 3 and 4 took place in 2020. The Leeds EDS process will consistently be reviewed monthly by the Leeds NHS E&D Network to ensure continuity.


On the 8th December, Senior Officers with E&D expertise from the following organisations assessed information virtually presented by each NHS organisation in Leeds, to determine areas for improvement and good practice:

  • Leeds City Council
  • Luminate, Leeds City College
  • West Yorkshire Crown Prosecution Service
  • Voluntary Action Leeds

The following examples of good practice were presented by LTHT:

Goal 3 A representative and supported workforce

  • Inclusion Ambassadors Programme
  • BME Allyship

Goal 4 Inclusive leadership

  • Executive Sponsors of Staff Networks
  • Reciprocal Mentoring Programme

All examples were well received and upheld as good practice along with the following recommendations with regards to the Inclusion Ambassadors Programme:

  • Focus beyond Bands 8a and above to address under-representation across the whole of the Trust.
  • Ensure to review qualifications documented as essential, especially degrees for high level roles and qualifications for low-level entry into LTHT.
  • Ensure our recruitment panels are representative, including with regards to disability.

The following remedial actions are proposed to be incorporated into the E&D Delivery Plan as a result:

  • Review scope of Inclusion Ambassadors Programme.
  • Build into Stage 2 of the Inclusion Ambassadors Programme the necessity for Inclusion Ambassadors to be involved in the job specification prior to release and a requirement to check qualifications requested.
  • Review how the Trust ensures recruitment panels are representative and develop remedial action where appropriate.
  • Review extent at which employability schemes are accessible to all protected groups.