The patient and carer race equality framework (PCREF) is an NHS England initiative designed to reduce racial inequalities in mental health services, by helping organisations review and improve how they support patients and carers from diverse communities.

This page has an overview of our implementation plan for 2026-2027.

Purpose: To continue the establishment of the leadership, governance, engagement, communications, improvement, and reporting infrastructure required to deliver the patient and carer race equality framework. ​​To deliver measurable actions to address racial inequalities in access, experience and outcomes.

Monitoring: Monthly progress review in PCREF steering group, quarterly assurance to health inequalities oversight group and Pennine Care's Board (via chair’s report).

Focus area 1 - Create PCREF lead role and recruit

  • 1.1 Confirm post details (whole time equivalent, hosting arrangements, line management, budget split between PCREF lead and community engagement support).
  • 1.2 Finalise job description/person specification and evaluation (agenda for change job matching, banding confirmation) and secure approvals to advertise. Complete.
  • 1.3 Run recruitment campaign (targeted outreach through PCREF networks, voluntary, community and social enterprise​​​​​​ partners, staff networks; panel composition includes lived experience representation).
  • 1.4 Onboard PCREF lead: induction across quality, operations, equality, diversity and inclusion, business intelligence / analytics, communications, and external stakeholders; confirm priorities for first 90 days and reporting.
  • 1.5 Establish PCREF programme management: action tracker, risks/issues, impact recording, engagement log, and improvement portfolio register.

Focus area 2 - agree community engagement approach and plan

  • 2.1 Agree engagement principles and standards: co-production expectations, accessibility, safeguarding, payments/expenses, confideniality, feedback loops (“you said, we did”), and anti-tokenism safeguards.
  • 2.2 Define engagement model (for example, community leadership group hosted by/with voluntary, community and social enterprise​​​​​​; community listening events; ongoing feedback mechanism), including how it links to PCREF steering group decision-making.
  • 2.3 Commission / establish delivery mechanism: confirm route (in-house, voluntary, community and social enterprise​​​​​​ host, micro-commissioning) and contract management / governance arrangements.
  • 2.4 Produce 12-month engagement plan: priority communities (based on local population and inequality evidence), schedule of engagement, recruitment approach, comms channels, outputs required.
  • 2.5 Deliver initial engagement cycle and publish learning summary and agreed priorities.
  • 2.6 Close the loop with communities: share actions taken, what changed, and what will happen next; agree ongoing touchpoints.
  • 2.7 Agree onward engagement plan: create options paper for agreement of how community engagement will be sustained.

Focus area 3 - Embed in business plans: data quality, community connectors, quality improvement (QI)

  • 3.1 Confirm in year PCREF objectives included in business plans and accountable persons: minimum set covering (a) ethnicity data quality, (b) community connector roles, (c) QI to address racial inequalities.
  • 3.2 Data quality improvement plan: baseline missing/unknown ethnicity and other demographic fields; define standards, prompts/scripts, recording guidance, training offer, and local ownership; agree monitoring.
  • 3.3 Define community connector role: purpose, responsibilities, time allocation, escalation routes, training/support, and links to engagement and quality improvement; publish role profile and toolkit.
  • 3.4 Confirm coverage and nominate/refresh community connectors across all care hubs and establish a community connector network meeting, forum or community of practice.
  • 3.5 Develop QI portfolio: select priority inequality themes using dashboard and community insight and existing patient and carer experience data (such as patient advice and liaison service and complaints); define aim statements, measures, and sponsor for each.
  • 3.6 Commence QI initiatives (at least 1 per care hub) using agreed methodology; ensure co-production involvement; report progress monthly.
  • 3.7 End-of-year learning, spread and forward plan: summarise what worked, impact on measures, and proposals for scale/spread Year 2 (including resource implications).

Focus area 4 -  communications for staff and communities

  • 4.1 Agree key messages and narrative: what PCREF is, why it matters, what will change, what staff must do (e.g., data quality, responding to feedback), and how communities will see impact.
  • 4.2 Publish ‘PCREF in a page’ and role/accountability map, making clear responsibilities for staff at each level in the organisation including board. 
  • 4.3 Launch internal comms: sign-off agreed plan to agree use of intranet hub, staff briefing pack, team brief content, frequently asked questions, and a schedule of updates; include ‘how to get involved’ routes (connectors, lived experience, QI projects).
  • 4.4 Commence targeted leadership engagement with onward plan: briefing for Trust Management Board, care hub leadership, and operational governance forums on expectations and responsibilities.
  • 4.5 Commence external/community communications with onward plan: accessible overview, community channels plan (voluntary, community and social enterprise​​​​​​ partners, faith groups, locality forums), and a clear feedback/contact route; publish ‘you said, we did’ updates.
  • 4.6 Comms evaluation: track reach/engagement (hits or reads, event attendance, community uptake), and adjust plan accordingly.

Focus area 5 - develop workforce cultural humility and competence training

  • 5.1 Agree training requirement: clear objectives for the outcomes from the training.
  • 5.2 Establish training offer: agree what the training offer will be, how it will be provided (including availability of external offers) and funded.
  • 5.3 Create training plan: ensure clear implementation with performance measures. 
  • 5.4 Monitor training plan: to be reported into appropriate forums including PCREF steering group. 

Focus area 6 - establish Care-hub PCREF delivery plans

  • 6.1 Create specification for what is required: clear guidance to support consistent understanding of requirements. 
  • 6.2 Communicate requirement: communicate requirement to care hub leads
  • 6.3 Create care hub PCREF plan with established governance: production of PCREF delivery plan with governance and leadership within each care hub
  • 6.4 Commence the monitoring of implementation and share good practice: via reporting into PCREF Steering Group and any other identified forums.

Focus area 7 - embed agreed governance structure

  • 7.1 Confirm governance map: reporting lines and decision rights between Trust Board, health inequalities oversight group, PCREF steering group, community leadership group (or equivalent), and workstreams (data, communications, workforce, community voice, improvement). Complete.
  • 7.2 Agree terms of reference and membership for PCREF Steering Group. Complete.
  • 7.3 Embed PCREF into Trust-wide governance structure: identification of appropriate forums within which PCREF will be standing item.
  • 7.4 Embed PCREF into existing care hub governance agendas: standing item and clear escalation routes across care hub quality/performance meetings and relevant committees.
  • 7.5 Agree annual cycle: self-assessment, quarterly review of dashboard and narrative, reporting to NHS England, and annual refresh of plan.
Focus area 8 - Develop and share PCREF dashboard
  • 8.1 Agree minimum viable dashboard and measures: confirm year 1 metrics aligned to PCREF reporting and local priorities; define data definitions and caveats (including missing ethnicity).
  • 8.2 Complete contextual population benchmarking across priority measures; for example, Mental Health Act detentions, restrictive practices, access) and build explanatory views (variation, trends, outliers).
  • 8.3 Define ‘so what’ workflow: for each dashboard page set out who reviews it, what questions to ask, what triggers escalation, and how actions are recorded and followed-up.
  • 8.4 Dashboard user testing and iteration with care hubs, community connectors and lived experience partners; improve usability and narrative.
  • 8.5 Trust-wide rollout: publish access route, training sessions/recordings, and embed in routine governance packs; provide a short ‘how to read the dashboard’ guide.
  • 8.6 Produce quarterly PCREF narrative pack combining dashboard trends, community insight and actions taken, for PCREF steering group, health inequalities oversight group and Board review and NHS England reporting.
Focus area 9 - Alignment of PCREF and Triangle of care
  • 9.1 Submission of PCREF Triangle of Care pilot site expression of interest: submit expression of interest to Carers Trust, within the required timescales, to participate as pilot site for revised PCREF informed Triangle of Care self-assessment tool. Complete.
  • 9.2 Develop PCREF / Triangle of Care action plan based on outcome of expression of interest: Develop actions under this section on PCREF plan to integrate Triangle of Care and PCREF work plans, informed by the outcome of the expression of interest to Carers Trust.
Focus area 10 - develop 3-year PCREF implementation plan for following years
  • 10.1 Develop a co-designed 3-year PCREF implementation plan (years 2–4): using year 1 learning, dashboard insight and community/staff priorities; define outcomes, resourcing, delivery milestones and governance; consult widely and secure approval.

Key dependencies and risks

  • PCREF lead recruitment timescales - job evaluation, approvals, ability to attract candidates may delay mobilisation.
  • Business intelligence or analytics capacity and data quality constraints may limit pace of dashboard development and usefulness until missing ethnicity improves.
  • Community engagement delivery route (in-house vs commissioned) may require additional procurement time and clear contract management.
  • Risk of ‘engagement without change’: mitigation is rapid feedback loops, visible service changes, and transparent reporting.
  • Competing operational pressures: mitigation is clear accountabilities in business plans and embedding review into routine governance.