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Action plan

This document demonstrates NHS Kernow’s Workforce Race Equality Standard (WRES) action plan in 2021 to 2022. This action plan should be read together with the WRES report.
2021 to 2022 WRES action plan

Complete and submit annual WRES return

Action 1

Return to be published on NHS Kernow website with accompanying information.

Expected outcome

Report annually on any gaps in experience between BAME colleagues and white colleagues. WRES return to highlight any areas of weakness, or areas for further progress, to inform WRES action plan. Compliance with NHS England standards. Clear review and publishing timescale. Openness and transparency for employees and members of the public.


WRES returns published annually. WRES returns are published on the NHS Kernow website. WRES race disparity ratios calculated in June 2021 and submitted to the national team.


31 March 2016 and annually thereafter.

Adoption of the WRES action plan

Action 2

NHS Kernow to monitor actions, compliance and update the action plan accordingly, to be published with the WRES return.

Expected outcome

To ensure that there is a consistent approach to working towards compliance with the WRES. WRES action plan informed by the WRES return. Action plan to demonstrate actions taken and progress. Compliance with NHS England standards. Clear review and publishing timescale. Openness and transparency for employees and members of the public.


This action plan accompanies the WRES return on the NHS Kernow website and demonstrates the actions being undertaken by NHS Kernow regarding the WRES.


31 March 2017 then annually.

Identification of a board lead for the WRES

Action 3

Expected outcome

Strategic opportunity to demonstrate their commitment to diversity and to leverage its potential to improve patient care.


Board lead for equality and diversity confirmed as Nicola Kelly, governing body lay member for patient and public involvement.


31 March 2017.

Review and monitor providers WRES reports

Action 4

Providers WRES reports to be reviewed on receipt, with comments returned to the provider.

Expected outcome

Acting as a responsible commissioner. Ensuring providers WRES returns are scrutinised and challenged as appropriate. Compliance with NHS England standards. Acting as a responsible commissioner.


Short pro forma developed to ensure NHS Kernow is reviewing and providing feedback in a consistent way. Reports reviewed when received, typically on an annual basis during the autumn following the national submission deadlines.

Log kept of indicators 5 to 8 for Cornwall Partnership NHS Foundation Trust (CFT), Royal Cornwall Hospitals NHS Trust (RCHT) and South Western Ambulance Service NHS Foundation Trust (SWAST). Log updated July 2021. A review of the available data shows that each provider has issues with each of the indicators 5 to 8. The percentage of different experiences varies from provider to provider and year to year. The percentage of BAME colleagues in each provider is low.

Indicator 5 is the percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months. The experience of white and BAME colleagues within SWAST is noticeably worse, compared to the other providers. The SWAST WRES action plan 2019 to 2020 outlines an action on staff training, to support equality, diversity and inclusion and challenge negative behaviours in relation to this indicator. Overall, the percentage of colleagues experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months is slightly worse for BAME colleagues, though this varies year on year.

Indicator 6 is the percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months. The data for this measure has been relatively stable since 2015. In 2019 and 2020, CFT has reported less harassment, bullying or abuse from staff experienced by BAME colleagues compared to white colleagues. Overall, there remains a small disparity between the experiences of BAME colleagues and white colleagues within this measure.

Indicator 7 is the percentage of colleagues believing that the organisation provides equal opportunities for career progression or promotion. There has been a small improvement of the experience of BAME colleagues since 2015. This narrows the gap in terms of experience of BAME colleagues and white colleagues. However, the percentage believing that the trust provides equal opportunities for career progression or promotion remains below the average for white colleagues. This is consistent across the three providers examined.

Indicator 8 is whether in the last 12 months a person has personally experienced discrimination at work from a manager/team leader or other work colleagues. Since 2015, the experience of BAME colleagues has been consistently worse. Approximately twice the number of staff from a BAME background have experienced discrimination from their manager or team leader, according to this measure.


Ongoing, typically annually per provider.

Benchmark NHS Kernow’s WRES performance

Action 5

Expected outcome

To ensure that our figures and feedback is broadly in line with other similar clinical commissioning groups (CCGs) across the country, or to highlight where additional action needs to take place as a result. To include key findings from the NHS national staff survey.


As NHS Kernow’s percentage of BAME staff is low, it has not been possible to undertake an analysis to compare against other CCGs for indicators 1 to 4.

The data for indicators 5 to 8 is sourced from the NHS national staff survey, which allows a comparison with other CCGs. However, the NHS national staff survey does not supply a breakdown of key WRES measures for BAME colleagues.

The following are NHS Kernow’s results from NHS national staff survey, conducted between 2015 and 2020. The last survey was conducted in September 2020 and received March 2021.

Percentage of staff who did not experience harassment, bullying or abuse from patients, relatives or the public in last 12 months (reference Q13a):

  • 2015 – 84%
  • 2016 – 82%
  • 2017 – 75%
  • 2018 – 86%
  • 2019 – 85%
  • 2020 – 87%

Percentage of staff who did not experience harassment, bullying or abuse from managers in last 12 months (reference Q13b):

  • 2015 – 83%
  • 2016 – 81%
  • 2017 – 82%
  • 2018 – 88%
  • 2019 – 86%
  • 2020 – 90%

Percentage of staff who did not experience harassment, bullying or abuse from other colleagues in last 12 months (reference Q13c):

  • 2015 – 88%
  • 2016 – 84%
  • 2017 – 83%
  • 2018 – 84%
  • 2019 – 85%
  • 2020 – 86%

Percentage of staff believing that the organisation provides equal opportunities for career progression or promotion (reference Q14):

  • 2015 – 78%
  • 2016 – 76%
  • 2017 – 75%
  • 2018 – 82%
  • 2019 – 91%
  • 2020 – 86%

In the 12 last months have you personally experienced discrimination at work from manager/team leader or other colleagues (reference Q15b):

  • 2015 – 5%
  • 2016 – 4%
  • 2017 – 8%
  • 2018 – 5%
  • 2019 – 3%
  • 2020 – 4%

Not experienced discrimination from patients/service users, their relatives or other members of the public (reference Q15a):

  • 2015 – 99%
  • 2016 – 99%
  • 2017 – 97%
  • 2018 – 100%
  • 2019 – 99%
  • 2020 – 99%

The improvement during recent years means NHS Kernow is performing at or above the national average for CCGs across three of the above indicators.



Development of an acceptable behaviour policy

Action 6

With oversight by the staff voice with a specific focus in the policy on the experiences of BAME colleagues.

Expected outcome

To ensure all colleagues are supported by the organisation.


Policy published in 2018 and operational with lunch and learns held. The policy is being revisited during 2021 in line with our typical 3-year review process.


April 2018.

Equality analysis of recruitment, workforce and leadership

Action 7

Expected outcome

To ensure that the organisation is recruiting and managing its employees fairly. To ensure that the organisation is broadly representative of the local population and there is no unintended discrimination.


Strategic commitment

As part of the NHS people plan submission, NHS Kernow has committed to 5 strategic employment areas of which 2 are expected to have a direct positive impact on workforce equality:

Key area 3: Equality, fairness and inclusion. Aim to have an inclusive culture where we all demonstrate the values of NHS Kernow.

  • Meet the legal requirements set out within the WRES and workforce disability equality standard (WDES) responsibilities.
  • Support effective diversity awareness, demonstrating positive changes in our culture towards more progressive and tolerant attitudes.
  • Integrate an inclusive recruitment model based on NHS employers disability recruitment guidance and introducing values-based methodology.

Key area 4: Improvement and development culture. Aim to support a culture where all staff realise their potential and promote continuous development.

  • To demonstrate ambitious aspirations for a developing leaders programme to support cultural positive change.
  • To support a culture where learning is seen as a priority and a right for every member of staff at the CCG.
  • Effective utilisation of regional and national programmes of development such as Kings Fund and Leadership Academy.
  • To actively encourage upward feedback within remit of reverse mentoring and 360-degree appraisal to support the development of staff and leaders.

In line with the NHS people plan submission, and the Cornwall and Isles of Scilly leadership board recommendations, NHS Kernow is committed to working with our integrated care system partners on recruitment and promotion overhaul action plans.


NHS Kernow mandates equality and diversity training for all NHS Kernow colleagues. ACAS dignity at work training was delivered for 2 successive years, with 65% of the workforce attending. Training for managers is commissioned by the people and organisational development team and this is linked to actions in the recruitment and promotion overhaul action plan.

Monitor the workforce ethnicity

A regular check to ensure colleague self-declaration on ethnicity reporting is near or at 100%. This is undertaken and reported within the equality information paper. No issues found in equality information published May 2021. There remain a small percentage of colleagues and applicants who opt not to declare their ethnicity and this has reduced slightly compared to the 2020 data. Colleagues are encouraged to view and update their ESR record as part of the self-service facility available to them.

The COVID-19 pandemic has highlighted the importance of having good quality information about our workforce. During 2021, an ESR data cleanse is taking place. Part of the schedule of work for the data cleanse includes updating protected characteristics on ESR, which includes ethnicity. The data cleanse has noted that the recruitment data from TRAC no longer automatically updates the protected characteristic fields in ESR; further work will be undertaken by the people and organisational development team to understand and mitigate against this.

Analysis of the workforce and leadership

Analyse the workforce and organisational leadership profiles, compared with our population. To ensure that the organisation is broadly representative of the local population and there is no unintended discrimination. This is undertaken through equality information, dated May 2021. No issues found in equality information published.

Disciplinary process

Monitor the relative likelihood of BAME colleagues entering the formal disciplinary process compared to white colleagues. To ensure that NHS Kernow is aware of the rate of disciplinary processes and relative likelihood for colleagues entering this process and tackle any proportionate gap in this rate, in line with NHS England’s strategy: a fair experience for all.

Monitoring of numbers entering the disciplinary process is undertaken with each completed WRES return. Small numbers of colleagues in NHS Kernow means this measure should be treated with caution. Further action will be taken should we identify an issue with disciplinary numbers or proceedings in future.

Conversations about workplace opportunities

Conversations are to be organised with BAME colleagues about secondment, acting up and development opportunities.

This is done at the yearly appraisal for all colleagues. There are no statistically significant differences in reported rate of appraisals for BAME colleagues compared to non-BAME colleagues. This is linked to actions within the recruitment and promotion overhaul action plan.



Advertise equality related opportunities to colleagues

Action 8

Expected outcome

To improve the opportunities of colleagues in the workforce and upskilling of the workforce. Address equality concerns in the workforce, with opportunities to be communicated to all colleagues.


Information about policies, programmes and opportunities is to be supplied to colleagues to further raise awareness and support improved understanding and awareness of equality and diversity within the organisation. The impact of COVID-19 has meant that many training courses previously available have been suspended. Some equality related opportunities offered to colleagues are included below.

  • The funded Leadership Academy’s Stepping Up programme for BAME colleagues advertised in the CCG’s weekly bulletin during January 2017, September 2018, July 2019 and December 2019. Due to COVID-19, the programme has been suspended but will be re-advertised to NHS Kernow colleagues when available.
  • A call for BAME representation to be part of the local learning disabilities mortality review steering group was put out in November 2020.
  • Resilience and wellbeing at work sessions held during 2018, 2019 and 2021.
  • ACAS and EASS webinar offered about discrimination at work offered in January 2020.
  • Mental health first aid training delivered to several colleagues in 2017 and was refreshed in July 2019.
  • Suicide first aid training and suicide prevention training offered March to May 2021.
  • The opportunity to become a Stonewall Ally made available to all non-LGBT colleagues in March 2019.
  • Advertising opportunities for people to attend the multiagency networks, including lesbian, gay, bi, trans, queer or questioning (LGBTQ+) employee network group, BAME network meeting and disability staff network.
  • Cultural capability training offered to NHS Kernow colleagues during July to December 2019.
  • Diversity development and training opportunities shared with finance team colleagues in line with the future focused finance programme. Information shared September 2019.
  • ILM Level 5 certificate in coaching and mentoring BAME cohort. Advertised to NHS Kernow and GP colleagues in October and November 2019.
  • Personalising leadership for wellbeing, equality and inclusion, started in March 2021.
  • Information and training sessions delivered regarding the accessibility regulations 2018 from November 2020 onwards.
  • Advertised the importance of the freedom to speak up in June 2020, specifically in relation to the impact of COVID-19 on BAME colleagues.
  • Advertised health and wellbeing offers, including NHS digital weight management programme, with greater access for people from a BAME background.

In addition, equality impact assessment and full impact assessment templates and guidance are available and routinely promoted. Offers of support are provided by equality and diversity manager regarding impact assessments.

Colleagues continue to be reminded about the importance of WRES. The revised policy on policies, implemented in July 2018, actively reinforces the need for robust impact assessments to be completed prior to consulting on new and amended policies, revised accordingly following any feedback to ensure risks identified are mitigated wherever possible. Without this in place, policies cannot be approved.



Respond to the COVID-19 pandemic

Action 9

Expected outcome

Where possible, mitigate against the negative effects of the COVID-19 pandemic on colleagues who may be more vulnerable, due to a, or multiple, protected characteristics.


NHS Kernow has experienced unprecedented change in 2020 and 2021 due to the COVID-19 global pandemic. Much of NHS Kernow’s work during 2020 was impacted by COVID-19 and the need to support colleagues to work safely. We recognise the importance of supporting those potentially most vulnerable to COVID-19, which includes people from a BAME background. Actions taken include:

  • risk assessments completed to understand the health risk to each colleague, enabling mitigating actions to take place
  • enabling colleagues to work from home
  • having a process to enable access to an office space for those who need this, for their health and wellbeing
  • development and review of strategies and policies, especially those with a focus on supporting people to work remotely
  • sharing events and listening events to understand how NHS Kernow can better support colleagues in the context of COVID-19, agile working and the establishment of an integrated care system
  • promoting the uptake of the COVID-19 vaccines, including through sharing videos, which include people from a BAME background
  • sharing easy read information about COVID-19
  • providing advice and guidance for colleagues working from home with children


March 2020 onwards.

Transfer learning from NHS Kernow’s involvement in the Stonewall project

Action 10

Expected outcome

As a former diversity champion, NHS Kernow can share learning from the work within out prejudice, celebrate diversity, across other protected characteristics.


The initial focus of out prejudice, celebrate diversity was on colleagues who identify as LGBT. This work is transferring to consider those who are from a BAME background, initially regarding good practice around networks, and allyship.


January 2019 and ongoing.

Implement the leadership board recommendations

Action 11

The Cornwall and Isles of Scilly leadership board has co-produced 7 recommendations relating to race.

Expected outcome

To improve the experience of BAME colleagues in NHS Kernow’s workforce. Contributing to a working environment where BAME colleagues feel supported. Build trust and confidence of BAME people in our community.


NHS Kernow is supportive of both the collective and individual board recommendations made by the Cornwall and Isles of Scilly leadership board.

In support of the recommendations, NHS Kernow has undertaken the following actions:

  • joined the reformed hate-crime steering group
  • agreed to financially contribute to the Cornwall Race Equality Forum
  • formulated an initial action plan with integrated care system partners for the recruitment and promotion overhaul, which focuses on people from a BAME background
  • held recent discussions to extend the membership of NHS Kernow’s citizen advisory panel that actively supports NHS Kernow in community engagement
  • our governing body lay member for patient and public involvement has participated in the Cornwall Race Equality Forum meeting

NHS Kernow will also do the following:

  • review NHS Kernow’s equality and diversity website wording
  • review existing equality and diversity related policies ensuring a strong focus on anti-racism, adoption of race charters and reference to hate crime
  • continue to work collaboratively with our ICS partners on the review of recruitment and promotion practices and outcomes
  • utilise a new equality objective to institute a programme of involvement with and support for awareness campaigns
  • work to strengthen the robustness of ethnicity data collection and use it to provide insight and identification of shared priorities
  • review additional opportunities to train colleagues and improve awareness of diversity, inclusion and equality matters and to support and empower colleagues to take action to improve their own and colleagues’ experiences at work


March 2021 onwards.

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