NLP Planned Orthopaedic Surgery for Adults · NLP Planned Orthopaedic Surgery for Adults - Health Inequalities and Equalities Impact Assessment 6 2. BACKGROUND North London Partners

NLP Planned Orthopaedic Surgery for Adults- Health Inequalities and Equalities Impact Assessment

NLP P lanned Orthopaedic Su rgery

fo r Adu l t s Health Inequalities and Equalities

Impact Assessment

Author: Sue Clegg and Clive Caseley

Date: December 2019

The Fold Space,

20 Clyde Terrace

London SE23 3BA

REG VAT GB 858230025

Registered in England Company

Number 05358457

Registered office:

24 Old Bond Street, London W1S 4AP

+44 207 017 2011 [email protected]

www.vervecommunications.co.uk

CONTENTS

1. EXECUTIVE SUMMARY 3

ABOUT THIS REPORT 3

APPROACH 4

MAIN IMPACTS AND MITIGATIONS 4

2. BACKGROUND 6

3. THE NEED FOR AN HEALTH INEQUALITIES AND EQUALITY IMPACT ASSESSMENT 8

HEALTH INEQUALITIES 8

EQUALITY IMPACT ASSESSMENT 8

FULFILLING THE REQUIREMENTS 9

4. PROTECTED CHARACTERISTIC GROUPS 10

5. VERVE COMMUNICATIONS 11

6. OVERVIEW OF THIS REPORT 12

7. CURRENT ARRANGEMENTS FOR PLANNED ORTHOPAEDIC SURGERY FOR

ADULTS IN NCL 14

THE NEED FOR CHANGE 15

7.1.1 Waiting lists 15 7.1.2 NHS targets 15 7.1.3 Cancellations 15

7.1.4 Increase in demand 15 7.1.5 Variation in patient experience 15

8. PROPOSED FUTURE ARRANGEMENTS FOR PLANNED ORTHOPAEDIC SURGERY

FOR ADULTS IN NCL 16

SERVICE LOCATIONS AND PROVIDER PARTNERSHIPS 17

PATIENT PATHWAYS 18

8.2.1 Pathway for patients requiring an overnight stay 18 8.2.2 pathway for day case patients 18

MITIGATIONS BUILT INTO THE MODEL 18

9. CHANGE POINTS ARISING FROM THE PROPOSALS 20

SERVICE MODEL CHANGES 20

PATHWAY CHANGES 22

10. METHODOLOGY 23

HOW PREVIOUS WORK FED INTO PHASE 2 23

PHASE 2 23

STAKEHOLDER WORKSHOP 27

11. POPULATION DENSITIES OF THE SCOPED IN GROUPS 29

mailto:[email protected]

The Fold Space,

20 Clyde Terrace

London SE23 3BA

REG VAT GB 858230025

Registered in England Company

Number 05358457

Registered office:

24 Old Bond Street, London W1S 4AP

+44 207 017 2011 [email protected]

www.vervecommunications.co.uk

THE POPULATION OF NCL 29

PEOPLE AGED 65+ 29

DISABILITY 30

GENDER REASSIGNMENT 31

RACE 31

CARERS 34

SOCIO-ECONOMIC DEPRIVATION 34

12. FINDINGS 36

THE IMPACTS OF CHANGE PROVISION 36 12.1.1 Service model changes 36

12.1.2 Pathway changes 38

DISCUSSION OF THE IMPACTS OF THE CHANGES 39 12.2.1 Locations of care provision 40

12.2.2 Changes to reduce cancellations 45 12.2.3 Changes to manage complicated and deteriorating patients 46 12.2.4 Rehabilitation services available 7 days a week 46

12.2.5 Changes to improve the care pathway 47

13. CONCLUSIONS 48

RECOMMENDATIONS FROM THE INTEGRATED HEALTH INEQUALITIES AND EQUALITY

IMPACT ASSESSMENT FOR THE CONSULTATION PHASE 48 13.1.1 Recommendation 1 – Focus on positive steps to tackle inequality 48

13.1.2 Recommendation 2 – Prioritising people for whom equalities impacts are likely

to be highest 49 13.1.3 Recommendation 3 – Targeted approaches to engagement where

necessary 50 13.1.4 Recommnedation 4 - Ensuring follow-through 50

RECOMMENDATIONS FROM THE MOTT MACDONALD TRAVEL ANALYSIS 50

mailto:[email protected]

NLP Planned Orthopaedic Surgery for Adults - Health Inequalities and Equalities Impact Assessment

3

1. EXECUTIVE SUMMARY

ABOUT THIS REPORT

This Integrated Health Inequality and Equality Impact Assessment (HIEIA) forms part of an

Integrated Impact Assessment to support consultation on proposals for change to planned

orthopaedic surgery for adults in North Central London (NCL) and surrounding areas.

When major changes to NHS services are proposed there are statutory requirements derived from

the Equality Act 2010 to consider equalities and health inequalities.

For those commissioning or providing public services, there are two principle duties:

1. Meet the Public Sector Equality Duty (PSED)

2. To take account of the likely implications for changes to services or the location or access

arrangements for groups or individuals protected under the Act.

An Equality Impact Assessment (EIA) is part of a structured process to meeting these duties and

taking equality of opportunity into consideration when proposing changes to services.

To fulfil these requirements North London Partners in health and care (NLP) has commissioned two

independent pieces of work to examine the effects the changes might have on groups of

people sharing protected characteristics:

● This HIEIA report looks at whether there are any health or other inequalities which are

likely to arise from the changes to the provision of planned orthopaedic surgery for adults

in NCL.

● A separate, but linked, report by Mott MacDonald considers the travel implications of the

changes, which includes demographic profiling of local people who might be required

to travel for planned orthopaedic surgery and hence identifies some groups sharing

protected characteristics under the Act or experiencing social deprivation, and a

detailed review of modes of travel and transport identifying potential barriers and

mitigations for these groups.

This report concludes that generally the changes are likely to have positive impacts for all

patients, and for some scoped-in groups in particular. Sixteen positive impacts were identified

and one negative impact. The negative impact arises from proposed changes to the location of

some services in future. Some early ideas for mitigations are offered in the final chapter.

This report was produced independently by Verve Communications. It complements and draws

on analysis undertaken to inform the travel assessment and will be supplemented by further work

during and following public consultation.


4

APPROACH

The purpose of this report is to:

● Identify any positive or negative impacts for NCL residents within protected characteristic

groups resulting from proposed changes

● Make recommendations for the consultation period

● Offer initial thoughts on mitigations.

To achieve this, a structured approach was taken to understanding which groups would be

impacted as a direct consequence of the changes to the service model and to defining

‘change points’ within the new model and proposed service locations which enabled a

prioritised set of impacts (both positive and negative) to be identified for more detailed

consideration:

● The starting point was nine protected characteristics groups protected under the Act,

and NLP also chose to scope in people with caring responsibility and deprived

communities to ensure that inequalities derived from these characteristics were also

reflected.

● From this, a longer-list was developed to consider differential impacts which may be

relevant (e.g. for people experiencing physical access as distinct from other groups

within the disability protected characteristic who may have specific health conditions

related to surgery or visual impairments). This led to 30 identified sub-categories.

● Detailed review of the proposed model and an understanding of specific groups and

communities who may be disproportionately impacted derived from population data,

enabled sixteen key ‘change points’ to be identified.

● Through a facilitated process involving patient representatives, service managers and

front-line clinicians, the groups most likely to be impacted was developed from the wider

group and tested with stakeholders and the NLP equalities lead. Through this process six

broad groups were identified as priorities for assessment.

MAIN IMPACTS AND MITIGATIONS

Impacts due to the following are considered in depth in this report:

● Proposed change of some locations of care provision

● Proposed changes likely to reduce cancellations

● Proposed changes to management of complex or deteriorating patients

● Proposed changes to rehabilitation following surgery

● Proposed changes to streamline the care pathway.

Recommendations for engagement during the consultation phase are made to ensure that:

● Mitigations are considered and patients and stakeholders asked to propose solutions to

potential negative impacts

● Prioritising engagement with people for whom impacts are likely to be highest


5

● Targeted approaches to engagement of specific cohorts of patients

● Engagement with providers supports them to understand impacts and develop solutions.


6

2. BACKGROUND

North London Partners in health and care (NLP) is proposing changes to the way in which

planned surgery for adults requiring planned orthopaedic surgery is delivered. The changes will

affect residents of Barnet, Camden, Enfield, Haringey and Islington, as well as small numbers of

patients from other areas who travel to north central London (NCL) for orthopaedic surgery.

Demand for planned orthopaedic operations for adults has been growing and the NHS is

struggling to offer treatment in a timely way to patients. As well as growth in demand planned

surgery is frequently cancelled due to emergency care taking priority, especially in winter.

The hospitals across north central London have worked together to find a new way to organise

planned orthopaedic surgery for adults which will greatly improve care for local people. The

changes aim to ensure equity of access to high quality care, address unwarranted variation in

the quality of care, increase capacity for planned orthopaedic operations, reduce cancellations

and make better use of the money available for this kind of care.

The review team led an engagement process between August and October 2018, during which

there was extensive involvement by residents, patients and individuals and groups bringing the

views of service users, local third sector organisations, equalities groups and north London’s

diverse communities.

During this phase, a desktop equalities review (Initial Equalities Analysis) was undertaken. This

considered potential impacts on groups sharing protected characteristics defined by the Equality

Act 2010 based on the geography and demographics of the north central London population

and the existing patient pathway. Its purpose was to inform development of the service model.

This paper builds on findings in both the engagement report and the desktop review which can

be found here:

● https://www.northlondonpartners.org.uk/downloads/plans/Adult-elective-orthopaedic-

review/End%20of%20engagement%20papers/North%20London%20Partners%20Review%2

0Group_Summary%20of%20Engagement%20Evaluation.pdf

● https://www.northlondonpartners.org.uk/downloads/plans/Adult-elective-orthopaedic-

review/End%20of%20engagement%20papers/North%20London%20Partners%20EIA%20sc

oping%20for%20engagement%20Final.pdf

Between November 2018 and January 2020, the model was developed and considered by both

the north central London Joint Overview and Scrutiny Committee and the Joint Commissioning

Committee of the NCL clinical commissioning groups (CCGs).

During the summer of 2019, providers were invited to make proposals for delivery of the agreed

model and an options appraisal process was undertaken to develop and evaluate options to be

taken forward to consultation.

https://www.northlondonpartners.org.uk/downloads/plans/Adult-elective-orthopaedic-review/End%20of%20engagement%20papers/North%20London%20Partners%20Review%20Group_Summary%20of%20Engagement%20Evaluation.pdf



https://www.northlondonpartners.org.uk/downloads/plans/Adult-elective-orthopaedic-review/End%20of%20engagement%20papers/North%20London%20Partners%20EIA%20scoping%20for%20engagement%20Final.pdf




7

The review team is currently planning a consultation exercise, which it is anticipated will

commence early in 2020. This document will inform that process.


8

3. THE NEED FOR AN HEALTH INEQUALITIES AND EQUALITY

IMPACT ASSESSMENT

HEALTH INEQUALITIES

The King’s Fund and Nuffield Trust published a report1 in 2017 which made recommendations for

the successful implementation of the five NHS Sustainability and Transformation Plans for London.

In response the Mayor of London developed a six test framework for major hospital

reconfiguration2; Test 1 relates to health inequalities and the prevention of ill health:

“The impact of any proposed changes on health inequalities has been fully considered

at an STP level. The proposed changes do not widen health inequalities and, where

possible, set out how they will narrow the inequalities gap. Plans clearly set out proposed

action to prevent ill-health.”

The work reported herein has considered the proposed changes to planned orthopaedic surgery

for adults in north central London in light of this requirement and discusses health inequalities

alongside potential inequalities for protected characteristic groups.

The five other Mayor of London tests are considered elsewhere.

EQUALITY IMPACT ASSESSMENT

Since the Equality Act 20103 has been law, public bodies are required to take account of the

needs of specific groups of people. In doing so, they can treat some groups differently – or more

favourably - in order to promote equality.

This aspect of the law (which also applies to employment practice) aims to ensure that services

are designed to meet the needs of everyone in the community and that people already at risk of

unequal treatment or outcomes, for example in health or educational attainment, are not further

disadvantaged by the actions of public service organisations.

When major changes to NHS services are proposed there are statutory requirements derived from

the Act to consider equalities and health inequalities.

For those commissioning or providing public services, there are two principle duties:

1. Meet the Public Sector Equality Duty (PSED), which means to consider, or have “due regard”

to their responsibilities to:

● Eliminate unlawful discrimination, harassment and victimisation and other conduct

prohibited by the Act

1 Sustainability and transformation plans in London, an independent analysis of the October 2016 STPs

(completed in March 2017) 2 https://www.london.gov.uk/what-we-do/health/champion-and-challenge/mayors-six-tests 3 https://www.legislation.gov.uk/ukpga/2010/15/contents/enacted

https://www.london.gov.uk/what-we-do/health/champion-and-challenge/mayors-six-tests

https://www.legislation.gov.uk/ukpga/2010/15/contents/enacted


9

● Advance equality of opportunity between people who share a protected characteristic

and those who do not

● Foster good relations between people who share a protected characteristic and those

who do not.

2. To take account of the likely implications for changes to services or the location or access

arrangements for groups or individuals protected under the Act.

An Equality Impact Assessment (EIA) is part of a structured process to meeting these duties and

taking equality of opportunity into consideration when proposing changes to services.

The principal components are:

● Review and analysis of the potential impacts of proposed changes, including

experience, accessibility and outcomes

● Identification of priority groups or communities protected under the Act who might

experience differential (especially adverse) impact

● Ensuring that the views of such groups are heard, and their interests are considered in

drawing up plans and making decisions

● Identification and implementation of mitigating actions which might address inequality

when changes are made and in future access and service delivery.

FULFILLING THE REQUIREMENTS

To fulfil the requirements for the consideration of health inequalities and equality impacts NLP has

commissioned two independent pieces of work to examine the effects the proposed changes

might have on groups of people sharing protected characteristics:

● This HIEIA report looks at whether there are any health or other inequalities which are

likely to arise from the proposed changes to the provision of planned orthopaedic

surgery for adults in NCL.

● A separate but linked report by Mott MacDonald considers the travel implications of the

proposed changes, which includes demographic profiling of local people who might be

required to travel for orthopaedic surgery and hence identifies some groups sharing

protected characteristics under the Act or experiencing social deprivation, and a

detailed review of modes of travel and transport identifying potential barriers and

mitigations for these groups. Where relevant the key findings from the travel impact

analysis are highlighted in this report.


10

4. PROTECTED CHARACTERISTIC GROUPS

The nine protected characteristics listed in the 2010 Act are:

● Age

● Disability

● Gender reassignment

● Marriage and civil partnership

● Pregnancy and maternity

● Race

● Religion or belief

● Sex (gender)

● Sexual orientation

The report also considers two other groups who could be disadvantaged by the proposed

changes:

● Carers

● People affected by economic deprivation


11

5. VERVE COMMUNICATIONS

Verve Communications Limited (Verve) is an independent full-service agency which supports NHS

organisations in delivering transformation and change. Over the past several years Verve have

supported NHS service configurations, institutional and major programmes of clinical change.

Verve has experience in successfully completing equalities impact assessments and can call on a

team of specialists to bring relevant expertise and insight.

This document has been produced independently by Verve and it represents our own analysis

and advice.

We are grateful for the assistance and support provided by NLP colleagues and the Mott

MacDonald team.


12

6. OVERVIEW OF THIS REPORT

This document reports on Stage 2 of a three-stage assessment process to develop an Integrated

Health Inequalities and Equality Impact Assessment (HIEIA) to ensure any decisions made will

advance quality and ensure fairness by removing barriers, engaging patients and community.

Stage 1 was a desktop review4 the output of which was a rapid scoping report which identified

potentially impacted groups. It was used to inform pre-consultation engagement activities in the

summer and autumn of 2018.

Stage 2 builds on Stage 1 and looks explicitly at the impact of the proposed model of care and

the proposed location of services. The output, this report, delivers an initial HIEIA identifying

positive and negative impacts resulting from the proposed changes and makes

recommendations for the consultation stage; it also offers some initial thoughts on mitigations to

reduce negative impacts.

Stage 3 will take place after the consultation period and will build upon the previous two stages.

It will deliver a revised and final integrated HIEIA, which will reflect the results of the public

consultation. The report will offer an updated mitigations schedule and suggest next steps.

The three stages are summaries below.

4 https://www.northlondonpartners.org.uk/downloads/plans/Adult-elective-orthopaedic-

review/End%20of%20engagement%20papers/North%20London%20Partners%20EIA%20scoping%20for%20enga

gement%20Final.pdf

COMPLETED

Stage 1

August 2018

•Desktop review

•Examined the groups likely to be affected by any proposed changes to planned orthopaedic care for adults

•Used to guide the development of proposals and related engagment

THIS REPORT

Stage 2

December 2019

•Initial Integrated Health Inequality and Equality Impact Assessment

•identify any positive or negative impacts for NCL residents within protected characteristic groups resulting from proposed changes

•makes recommendations for the consultation period

•offers initial thoughts on mitigations

TO FOLLOW

Stage 3

Post-consultation

•Revised Final Integrated Health Inequalities and Equalities Impact Assessment

• revisits the stage 2 in light of feedback from the consultation

•refines recommendations for mitigation

•suggests next steps





13

Figure 1 The scope of each stage

The objective for this work is to identify any positive or negative impacts for NCL residents within

protected characteristic groups, carers and those from areas of economic deprivation, resulting

from the proposed changes to the delivery of planned orthopaedic services for adults.

The report will describe the current arrangements for planned orthopaedic surgery for adults and

will go on to outline the proposed changes to model of care. The change points in the proposed

model will be identified. The methodology for considering scoped-in and scoped out groups is

discussed, together with the methods used for identifying potential impacts of service changes

on the scoped-in groups. The population densities of the scoped-in groups in NCL are given.

The findings section tabulates the positive and negative aspects of each change point for

scoped-in groups, and then discusses the impacts in more detail.

The final section of the report presents our conclusions and recommendations for the next phase

of the work. A list of recommendations made in the Mott MacDonald travel report is also

included.


14

7. CURRENT ARRANGEMENTS FOR PLANNED

ORTHOPAEDIC SURGERY FOR ADULTS IN NCL

In 2016/17 north central London hospitals carried out 23,000 planned orthopaedic operations;

approximately 12,000 of these were routine (non-complex) orthopaedic procedures which would

fall within the scope of the proposed changes.

Patients are currently seen and treated at 10 different hospital sites, both NHS and private, across

NCL, with many of the sites combining planned and emergency care, inpatient and day surgery.

The current locations of planned orthopaedic surgery in north central London are shown on the

map below.

Figure 2 Map showing current locations of planned orthopaedic surgery for adults in NCL

● North Middlesex University Hospital NHS Trust

● Royal Free London NHS Foundation Trust

Chase Farm Hospital

Royal Free Hospital

● University College London Hospitals NHS Foundation Trust

University College London Hospital

National Hospital for Neurology and Neurosurgery


15

● Whittington Health NHS Trust

● Royal National Orthopaedic Hospital NHS Trust

● The Cavell Hospital (BMI Healthcare)

● Highgate Private Hospital (Aspen)

● The Kings Oak Hospital (BMI Healthcare)

Within current arrangements, Barnet Hospital offers outpatient appointments, but does not offer

orthopaedic surgery

THE NEED FOR CHANGE

Although the current provision of planned orthopaedic surgery for adults in NCL is of good

quality, improvements were identified to enhance patient experience and improve health

outcomes.

7.1.1 WAITING LISTS

In January 2019 there were 10,500 patients on waiting lists for planned orthopaedic surgery; there

was a 24% increase in the numbers of patients waiting for surgery between January 2018 and

January 2019.

7.1.2 NHS TARGETS

The NHS expects 92% of patients to have started treatment within 18 weeks of referral by their GP;

however, on average, between January 2018 and January 2019, only 79% of patients referred for

planned orthopaedic surgery in NCL started treatment within 18 weeks, with some hospitals falling

as low as 65% in winter months.

7.1.3 CANCELLATIONS

In 2018/19 530 orthopaedic operations were cancelled across NCL, 96% of which were cancelled

on the day of surgery. This equates to ten cancellations a week. The main reason for

cancellations were the demands of emergency cases which can result in beds not being

available or staff being called away at short notice.

7.1.4 INCREASE IN DEMAND

The demand for planned orthopaedic surgery for adults, such as hip and knee replacements, is

expected to increase by around 9.5% by 2029. The current arrangements would find it very

challenging to meet this increase in demand and waiting lists could increase.

7.1.5 VARIATION IN PATIENT EXPERIENCE

There are variations between hospitals in terms of time spent in hospital, infection rates and the

number of patients needing revision surgery.


16

8. PROPOSED FUTURE ARRANGEMENTS FOR PLANNED

ORTHOPAEDIC SURGERY FOR ADULTS IN NCL

The proposed changes to arrangements for planned orthopaedic surgery for adults in NCL have

been clinically driven and co-created with local people and NHS staff with the aim of improving

patient experience and outcomes and ensuring a service fit for the future.

A joined-up approach to planned orthopaedic surgery for adults in NCL is proposed. This should

ensure that NCL residents have timely access to consistent, high-quality, orthopaedic surgery,

regardless of where they live in the area.

Two partnerships have been formed by local NHS trusts – with North Middlesex University Hospital

(North Mid) working with The Royal Free London and University College London Hospital (UCLH)

and Whittington Health working together. The partnerships would be overseen by a network of

health professionals who will ensure that, regardless of where patients receive care, it is of a

consistently high standard. These new partnerships would deliver a new improved service.

The proposed service would have:

● Two NHS hospitals with dedicated operating theatres and beds, for patients who need to

stay overnight after their operation

● A choice of NHS hospitals for those needing day surgery

● Within each partnership, a choice of NHS hospitals for outpatient appointments

● Improved education classes for patients so they understand their operation and what to

do to before surgery to support their recovery afterwards

● Appointments would be with a named surgeon, who, with their surgical team, would stay

with patients throughout their care, regardless of where it takes place

● Rehabilitation support for patients after their surgery

● Access to high dependency or intensive care units for patients who need additional care

after their surgery

● Care coordinators to support patients with conditions such as dementia or a learning

disability to understand their care and where it might take place

● More complex surgery would continue at the Royal National Orthopaedic Hospital, a

super-specialist centre

● Patients with other complex medical conditions, such as haemophilia, will have their

surgery at the hospital which specialises in their condition

● Emergency orthopaedic care would continue at all local hospitals with an Accident and

Emergency department


17

SERVICE LOCATIONS AND PROVIDER PARTNERSHIPS

The proposed service locations and provider partnerships are shown in the map below:

Figure 3 Map showing proposed service locations and provider partnerships


18

PATIENT PATHWAYS

8.2.1 PATHWAY FOR PATIENTS REQUIRING AN OVERNIGHT STAY

Figure 4 Patient pathway for those needing an overnight stay

8.2.2 PATHWAY FOR DAY CASE PATIENTS

Figure 5 Patient pathway for day case patients

MITIGATIONS BUILT INTO THE MODEL

Comprehensive early engagement with patients influenced NLP’s thinking and ensured that

some mitigations for concerns were built into the proposed model at an early stage. The analysis

in this report takes this work into account and acknowledges that a great deal of work has

already been undertaken to ensure that equalities considerations are central to the proposed

model.


19

The concerns and mitigations are shown in the table below.

Concerns raised: Influence on thinking:

Patient experience:

o Patients with vulnerabilities might find it

difficult to travel to, and find their way

around, different hospitals

o Clinical delivery model: Inclusion of care

co-ordination function

o Options appraisal: Scored section on

patients with vulnerabilities within the

patient experience section

Continuity of care:

o Location of pre-operative assessments

and post-operative care/rehabilitation

were a concern

o Clinical delivery model is specific about

which organisation is responsible for pre-

operative assessment and patient

education sit in the pathway

o Options appraisal: providers asked to give

detailed consideration of how they will

deliver both pre-operative assessment

and patient education in their proposals

Patients with complex needs:

o It was not clear where patients with

complex needs would have their surgery

o Clinical delivery model: To include an

essential requirement for all planned

orthopaedic surgery centres for adults to

have an HDU

o Options appraisal: Assessment of

proposals around inclusion of HDU, case-

mix and managing clinical complexity

Integration:

o Contributors stressed the importance of

joined-up working

o Integrated IT systems were also important

o Clinical delivery model: To include a

section on digital requirements

o Options appraisal: IT and digital

considerations are included as part of the

deliverability score

Travel:

o There were repeated comments

suggesting that an in-depth transport

analysis should be considered

o Clinical delivery model: To include a

section on travel and transport

arrangements

o Options appraisal: A detailed travel

analysis will need to be carried out and

published as part of the public

consultation

Table 1 Inbuilt mitigations


20

9. CHANGE POINTS ARISING FROM THE PROPOSALS

A number of ‘change points’ have been identified in the proposals. ‘Change points’ are the

elements of the proposed model of care that will be different for patients in future, if the

proposals are implemented, when compared with the current arrangements.

The tables below show service model and pathway changes being proposed, together with a

description of each change and the expected outcomes of the changes.

SERVICE MODEL CHANGES

Change Description Expected outcome

360 patients will

change location

from UCLH

360 patients who would have gone

to UCLH would in future go to the

Whittington for day surgery

Reduced cancellations

and waiting times

360 patients will

change location

from the

Whittington


to the Whittington would in future

go to UCLH for inpatient care


and waiting times

400 patients will

change location

from the North

Middlesex


to the North Middlesex would in

future go to Chase Farm for

inpatient care


and waiting times

80 NHS funded

private sector

patients will change

location

80 NHS funded patients who would

have received day surgery in

private sector provision5 would,

over time, have their surgery at

UCLH

Consistent high quality

integrated care.

1020 NHS funded

private sector

patients will change

location

1020 NHS funded patients who

would have received day surgery in

private sector provision would, over

time, have their surgery at Chase

Farm instead.


integrated care.

560 NHS funded

private sector

patients would

change location


have received inpatient care in


time, have their surgery at Chase

Farm instead.


integrated care.

40 NHS funded

private sector

patients would

change location


have received inpatient care in


time, have their surgery at UCLH

instead


integrated care.

225 patients

referred to RNOH

for non-specialist

care could change

location

225 patients referred to RNOH for

non-specialist care could be

suitable for treatment at Chase

Farm instead

Patients will be able to

access the right treatment

at the right time with

minimal delays

75 patients referred

to RNOH for non-

75 patients referred to RNOH for

non-specialist care could be

Patients will be able to

access the right treatment

5 The private sector hospitals referred to are Cavell, Kings Oak and Highgate Hospitals


21


specialist care

could change

location

suitable for treatment at UCLH

instead

at the right time with

minimal delays

Ring fenced beds There will be dedicated inpatient

beds for patients requiring in-patient

care


related to orthopaedic

trauma/non-orthopaedic

admissions, reduced

waiting times, reduced

infection rates, high

quality consistent care,

reduced revision rates and

readmissions

Dedicated theatres Dedicated theatre space able to

operate 7 days a week

Increased capacity,

reduced cancellations,

reduced waiting times,

reduced infection rates,

high quality consistent

care, reduced variation in

care, reduced revision

rates and readmissions

High Dependency

Unit6

A minimum level 2 high

dependency care available at all

sites carrying out surgery

Ability to manage

complicated and

deteriorating patients

safely and effectively on

site minimising the need

for transfer

Ability to manage

deteriorating

patients

Systems and processes in place to

effectively manage patients who

require more intensive treatment

including transfer to intensive care

Early identification of

patients who are likely to

require additional medical

support to enable care

plans to be initiated.

Patients receiving the right

care are the right time

through immediate

referral to the most

appropriate hospital that

meets their clinical need.

Robust pathways in place

to transfer patients to high

dependency or intensive

care

Senior overnight

medical cover

Medical cover 24/7 including

overnight provision on site

The needs of patients who

deteriorate unexpectedly

or who require more

complex intervention can

be safely and effectively

managed without transfer

improving patient

experience

Rehabilitation

services 7 days a

week

Ability to mobilise patients 7 days a

week

Providing effective

intervention, improving

6 Quality of care for all patients will be improved by the addition of HDUs


22


experience and reducing

length of stay

Table 2 Service model changes

PATHWAY CHANGES


NCL wide

Multidisciplinary

Team working

(MDT)

Robust structures in place to share

clinical learning and provide

specialist advice and support

regarding individual patients

Improving patient safety

and effectiveness leading

to reduced revision rates,

readmissions and

decreased length of stay

Care co-ordinators Care co-ordinator roles in place to

support patients in navigating the

system and accessing the right care

and support at the right time

Improved patient

experience and

effectiveness of care

resulting in decreased

length of stay and the risk

of readmission

Consistent referral

pathways and

criteria

NCL wide referral processes and

criteria to ensure care constancy

across NCL

Equitable care that ensure

all patients across NCL

receive the same high

quality access to services

Standardised

patient education

and information

NCL wide approach to pre- and

post-operative information and

patient education

Ensuring all patients

receive the same high

quality information and

advice

Consistent

approach to pre-

operative

assessment

Standardise NCL wide pre-

operative assessment practices and

protocols

NCL wide assessment

practices will ensure

clinical and social issues

are identified early and

needs based care plans

implemented

Surgeons follow the

patient7

Surgeons will follow the patient from

local hospital to planned

orthopaedic surgery centre to

ensure there is consistency of care

Improving patient

experience

Table 3 Pathway changes

7 This is not a change per se, as patients currently see the same surgical team pre-operatively and for

operations, however, patients were concerned that receiving care in different locations might mean different

surgical teams would do their operations. Reassurance about continuity of care is likely to improve patient

experience.


23

10. METHODOLOGY

HOW PREVIOUS WORK FED INTO PHASE 2

From August to October 2018 the NLP Programme Team talked to over six hundred people (a

combination of NCL NHS service users and stakeholders). People were specifically targeted for

engagement exercise based on the Stage 1 Desktop Review Equalities Impact Assessment.

People took part in thirteen workshops alongside potential service providers to develop ideas for

how the services could work in the future. Groups represented in the workshops included:

● Older people

● People from different ethnic backgrounds

● People with physical disabilities

● People with learning disabilities

● People with mental health conditions

● Women

● People from areas affected by socio-economic deprivation

● People who had undergone/were undergoing gender reassignment

Those involved in the options appraisal groups (who made up 50% of the panel) also contributed

to this phase.

The findings from these workshops have been integrated into this stage of the Integrated Health

Inequalities and Equality Impact Assessment.

PHASE 2

For the current phase (Phase 2) of the Integrated Health Inequalities and Equality Impact

Assessment no engagement with patients was undertaken. The aim of this work was to identify

positive and negative impacts resulting from proposed changes in the model of care delivery for

planned orthopaedic surgery for adults, particularly for people in protected characteristic

groups, carers and those affected by deprivation. Specifically, the work sought to identify which

groups needed to be ‘scoped-in’ for the consultation exercise and the following Phase 3

Integrated Health Inequalities and Equality Impact Assessment report.

A methodical approach was taken to understanding which groups would be impacted as a

direct consequence of the changes to the service model. This would ensure that specific

detailed analysis of impact (both positive and negative) was focused on those who would

experience change.


24

Figure 6 Process for identifying impacted groups

In order to understand how different groups might be affected by the proposed changes a

longlist of protected characteristic groups was compiled. The list started with the nine protected

characteristics described in the Equalities Act of 2010; each characteristic was looked at in detail

to determine whether any sub-groups needed to be added to ensure that all who share a

characteristic, and might be affected by the changes, had been considered; the Act and

associated documents were consulted to compile a longlist of protected characteristics. Carers

and those affected by socio-economic deprivation were also considered. The longlist was:

Protected

Characteristic

Group

Sub-categories

Age • Working age adults

• Adults over 65

Disability • Mobility

• Long-term conditions such as cerebral palsy

• Conditions such as cancer, HIV infection and multiple sclerosis

• Sensory impairments

• Fluctuating or recurring effects, e.g. rheumatoid arthritis, ME/chronic

fatigue syndrome, fibromyalgia, depression, epilepsy

• Progressing conditions e.g. motor neurone disease, muscular

dystrophy and some forms of dementia

• Auto-immune conditions e.g. systemic lupus erythematosis

• Organ specific conditions e.g. asthma, stroke, heart disease

• Developmental conditions e.g. autistic spectrum disorders, dyslexia

and dyspraxia

• Learning disabilities

• Mental health conditions e.g. anxiety, bipolar disorders, Obsessive

Compulsive Disorder, personality disorders, post-traumatic stress

disorder etc.

• Mental illnesses e.g. depression and schizophrenia

• Disability as a result of injury to the body, including the brain

Gender

reassignment

• People who have completed gender reassignment

• People who have not completed gender reassignment surgeries

Marriage and civil

partnership

• Marriage

• Civil partnership

Pregnancy and

maternity

Race • Sub-categories appropriate to the geographic area

Nine protected characteristics groups + carers and deprivation

Long-list of protected characteristics groups

• 30 sub-categories

Prioritised impact matrix developed

• 480 potential impacts

Impact analysis undertaken

• 6 broad groups identified

Testing and consensus

• Agreement was sought from stakeholders


25

Protected

Characteristic

Group

Sub-categories

Religion or belief • Sub-categories appropriate to the geographic area

Sex • Male

• Female

Sexual orientation • Consider whether to include sub-categories

Carers • Adults caring for adults (either could be patient)

• Adults caring for children with extra needs (adult would be patient)

• Young carers caring for adults (adult would be patient

• Paid carers

Socio-economic

deprivation

Table 4 Longlist of protected characteristics and other groups to consider

The long-list comprised 30 categories/sub-categories to consider.8

A ‘prioritised impact matrix’ was developed, allowing each of the 30 categories to be considered

against all the 16 service model and pathway change points (see section 7, above). Effectively,

the matrix showed service change points in columns and protected characteristics and

sub/groups as rows, giving a 30x16 table. Each of the 480 cells was considered in terms of

whether a service change was likely to affect a category or sub-category differentially or

disproportionately compared with the general population. Each cell was given a value of High,

Medium or Low for potential impact. High or Medium impacts could be positive or negative; a

Low impact indicated that little or no impact was likely.

Three expert analysts completed the matrix separately.

An example of a cell from one analysist’s matrix is given below:

Changes →

Ring fenced beds

Service Model or Pathway →

Service Model

Protected Characteristic

Sub-category

Disability Long-term conditions

High (positive) - fewer cancellations beneficial - can plan better e.g. when to stop medications pre surgery etc

Figure 7 Example of analytical matrix cell

8 We acknowledge that it is likely that people could fall into more than one category or sub-category in the

list above, however, it is beyond the scope of this exercise to consider the effects of intersectionality.

Analyst’s notes on the

effect of ring fenced

beds for people with

long-term conditions

– here the analyst has

said that a High

(positive) impact is

likely as fewer

cancellations mean

better planning is

possible etc.


26

The analysts then came together to compare their views. Where differences of opinion occurred,

the analysts debated their positions until agreement was reached. In the rare instances when

agreement could not be reached the higher or highest level of impact was the final outcome

(for example, if 2 analysts assessed a cell as being High and one assessed as Medium, and

agreement could not be reached, the final impact assessment for that cell would be High).

A master matrix was produced showing the agreed cell values for all 480 cells from which a

shortlist of scoped in protected characteristics and sub-categories was developed, to include all

characteristics and sub-categories for whom the analysts had assigned High or Medium impacts.

It was also decided to combine some of the sub-categories where the impacts were similar or

identical across the matrix.

Scoped in

groups

Sub-categories To include

Age Adults over 65

Disability Mobility

Long-term conditions • Long-term conditions such as cerebral

palsy

• Conditions such as cancer, HIV infection

and multiple sclerosis

• Fluctuating or recurring effects, e.g.

rheumatoid arthritis, ME/chronic fatigue

syndrome, fibromyalgia, depression,

epilepsy

• Progressing conditions e.g. motor neurone

disease, muscular dystrophy and some

forms of dementia

• Auto-immune conditions e.g. systemic

lupus erythematosis

• Organ specific conditions e.g. asthma,

stroke, heart disease

• Disability as a result of injury to the body,

including the brain

Sensory impairments

Developmental and

learning disabilities

• Developmental conditions e.g. autistic

spectrum disorders, dyslexia and

dyspraxia

• Learning disabilities

Mental health conditions

and mental illnesses

• Mental health conditions e.g. anxiety,

bipolar disorders, obsessive compulsive

disorder, personality disorders, post-

traumatic stress disorder etc.

• Mental illnesses e.g. depression and

schizophrenia

Gender

reassignment

• Include people who have/have not

completed gender reassignment

surgeries

Race • Describe potential differential needs of

some ethnic groups and note where


27

Scoped in

groups

Sub-categories To include

there are geographic hotspots – look for

impacts based on travel

Carers • Adults caring for adults

(either could be

patient)

• Adults caring for

children with extra

needs (adult would be

patient)

• Young carers caring for

adults (adult would be

patient)

Socio-

economic

deprivation*

Table 5 Shortlist of scoped in groups

*Socio-economic deprivation was scoped in because these are groups who might be negatively

affected if they need to travel further or have more complex journeys as a result of the changes.

There were no other positive or negative effects seen for this group.

The categories which were scoped out were: working age adults; marriage and civil partnership;

pregnancy and maternity; religion or belief; sex; sexual orientation; and paid carers. Categories

were only screened out when no differential or disproportionate impact from any of the service

change points were perceived, for example, whilst osteoporosis is more common in women who

consequently might have more need of planned orthopaedic surgery, no impacts from the

proposed service changes were perceived based on a person’s gender, therefore the category

of ‘sex’ (gender) was screened out.

STAKEHOLDER WORKSHOP

The scoped-in and scoped-out categories were presented to a validation meeting of the NLP

project team and agreement was reached on all categories. The categories were then

presented at a stakeholder workshop, which had the opportunity to discuss the categories and to

have input potential impacts and how these could be converted to opportunities for

improvement of the proposed models of care.

The following people attended the workshop:

● Patient representatives

● The NLP Programme Team

● Equalities Leads from NCL9 and North Middlesex University Hospital

● A GP Rep

● Stakeholders from:

9 Emdad Haque, Senior Equality, Diversity and Inclusion Manager, North Central London CCGs, was present at

both meetings and his expertise was invaluable in deciding on the scoped-in and scoped out groups.


28

NCL

UCLH

Royal Free Hospital

● Mott MacDonald team

● Verve team

The agenda of the workshop was:

● Introduction to the workshop

● Setting the scene – the review so far

● What are equalities analyses and why do we do them?

● Travel analysis – what is being looked at and early findings

● Equalities Impact Assessment – potential impacts from proposed changes to the service

model and care pathway

● Opportunities for improvement already in the proposed models

● Looking for further opportunities for improvement

● Table discussions on how specific potential impacts could be converted into

opportunities for improvement

● Feedback on the table discussions

● Closing statements

Potential opportunities for improvement, or mitigations, suggested during the Stakeholder

Workshop are presented in section 13.1.1

This HIEIA builds on an extensive pre-consultation engagement exercise and previous desktop

review, as described in Section 10.1.

These exercises involved engagement with groups sharing protected characteristics and were

key to setting the scope and method for this stage. During these exercises, sections (a) and (c) of

the public sector equality duty were considered. These relate to having due regard to the need

to eliminate discrimination, harassment and victimisation (section (a)) and to foster good relations

(section (c)).

Nothing in the responses to pre-consultation engagement indicated issues relevant to these

aspects of the duty. However, we note that NLP intend to ensure within the consultation period

that this is tested further, and we would expect to include any relevant findings and proposed

mitigations in our final report.


29

11. POPULATION DENSITIES OF THE SCOPED IN GROUPS

This section gives the population of NCL and the demographics of the scoped in groups

discussed in section 10. The maps also show the locations of NHS and private hospitals in NCL, for

reference.

THE POPULATION OF NCL

The estimated resident population of NCL in 2019 is approximately 1.5 million. Over the next

decade the NCL population is expected to increase by 9%10

The following map11 shows population density in NCL and surrounding areas

Map 1 Population density of NCL and surrounding areas

PEOPLE AGED 65+

The 2019 estimate of NCL residents aged over 65 is 182,00012, with an expected increase to

234,000 in the next ten years.

The map below shows the population density of people aged 65 and over in NCL and

surrounding areas. The data is derived from ONS Mid-year population estimates, 2018.

10 GLA 2017 based housing led population projections 11 The maps in this section were prepared by Mott MacDonald for the associated travel analysis for this project 12 GLA 2017 based housing led population projections


30

Map 2 Population density of residents aged 65+ in NCL and surrounding areas

DISABILITY

A survey13 has estimated that 14% of people aged 16-74 in the inner London regions live with

disabilities. The estimate of the NCL population in 2017/18 living with disabilities in 211,00014.

The map below shows the population density of people with long term health problems and

disabilities in NCL and surrounding areas. The data is derived from people reporting that they

had long-term health problems or disabilities in the 2011 Census.

13 2017/18 Family Resource Survey 14 2017/18 estimated calculated by the Public Health Knowledge and Intelligence team applying regional

prevalence to NCL boroughs.


31

Map 3 Population density of people with long term health problems and disabilities in NCL and

surrounding areas

GENDER REASSIGNMENT

At present there are no official estimates of the numbers of people who have undergone, or are

undergoing, gender reassignment either nationally or locally.

RACE

GLA 2016 based population projections show approximately 62% (943,000 people) of the NCL

population are from White ethnic groups; there is a lot of diversity amongst the rest of the

population, with 191,000 people being from Black ethnic groups, 94,000 describing themselves as

being in a ‘mixed’ ethnic group and 217,000 being from Asian ethnic groups15. The 2011 Census

showed that there were 70,324 Turkish people living in NCL.

The following maps show the population densities for White people, Black people, Asian people

and Turkish people. The data used to produce the maps is from the 2011 Census.

15 GLA 2016 based population projections


32

Map 4 Population density of White people in NCL and surrounding areas

Map 5 Population density of Black people living in NCL and surrounding areas


33

Map 6 Population density of Asian people living in NCL and surrounding areas

Map 7 Population density of Turkish people living in NCL and surrounding areas


34

CARERS

It is known that 17,520 people were in receipt of Carer’s Allowance16 across NCL in 2018, which

equates to 1.5% of the 18+ population.

For the purposes of the population density map, shown below, carers are those who described

themselves in the 2011 Census as providing 20 or more hours of unpaid care per week.

Map 8 Population density of unpaid carers in NCL and surrounding areas

SOCIO-ECONOMIC DEPRIVATION

The population density of socio-economic deprivation is derived from Indices of Multiple

Deprivation from the Ministry of Housing, Communities & Local Government, 2019.

16 DWP 2018


35

Map 9 Population density of socio-economic deprivation in NCL and surrounding areas


36

12. FINDINGS

This section of the report will discuss impacts of the proposed service change points (see section

7, above) in relation to the scoped-in groups outlined in section 9, above.

It is important to stress that impacts are analysed and described to enable the programme team

to consider them and develop a response as the programme progresses. Negative impacts are

not, in themselves, static – but should be seen as opportunities for further refinement of the

model. The consultation offers an ideal opportunity, in partnership with affected groups, to seek

the views of stakeholders in order to find suitable mitigations.

Both POSITIVE and NEGATIVE impacts are examined in the table. We have identified:

16 POSITIVE IMPACTS

1 NEGATIVE IMPACT

The section starts with a table showing where medium and high impacts of change might be

expected, and whether these are positive or negative impacts; there is then a discussion of what

the impacts are likely to be.

THE IMPACTS OF CHANGE PROVISION

The following tables show the proposed change points, their expected outcomes and our

evaluation of where High or Medium, positive or negative impacts might occur. Low impacts are

not shown as it is expected that there would be little or no impact.

12.1.1 SERVICE MODEL CHANGES

Change Expected outcome Impacts

Changes of location

Improved clinical outcomes

including reduced

cancellations, decreased


infection rates, decreased

revisions and readmissions.

The delivery of at-scale

orthopaedic surgery at

dedicated facilities would

result in consistently excellent

clinical interventions across

end-to-end pathways.


integrated care in NHS

provision for those moving

Potential for positive or

negative impacts

depending on where

patients live as journey

times may be shorter or

longer.17

HIGH POSITIVE impacts

for all patients, including

scoped in groups, re

reduction of

cancellations and

waiting times etc.

HIGH POSITIVE impacts

for people with

disabilities who have

17 It should be noted that patients can choose which partnership they are referred to for care, and they could

choose to go to a hospital which is geographically further from them.


37


from NHS funded private

sector care to NHS care.

Access to the right treatment

at the right time for those who

have been mis-referred to

RNOH for non-specialist care,

and who could be suitable for

NHS care in NCL

carers. More choice

would be available for

carers to stay overnight

with those they care for.

Currently UCLH offers this

facility and the

proposed changes

would see Chase Farm

having this provision too.

POSITIVE impacts for

people moving from NHS

funded private sector

provision into NHS

provision as they will

have access to

consistent high quality

integrated care

delivered by the NHS.

POSITIVE impacts for

those mis-referred to

RNOH for non-specialist

care as they would not

experience delays in

treatment arising from

mis-referral.

HIGH NEGATIVE impacts

possible for people with

disabilities (learning

disabilities, autistic

spectrum disorders etc),

carers and those

affected by socio-

economic deprivation

and some ethnic groups

who might have to travel

to different hospitals for

surgery, with potentially

more complex or longer

journeys.

Dedicated (ring fenced) beds for

patients requiring in-patient care


related to orthopaedic

trauma/non-orthopaedic

admissions, reduced waiting

times, reduced infection rates,

high quality consistent care,

reduced revision rates and

readmissions

MEDIUM/HIGH POSITIVE

impacts for all patients,

especially for those with

disabilities, carers and

those affected by socio-


Dedicated theatre space able to

operate 7 days a week

Increased capacity, reduced

cancellations, reduced


infection rates, high quality






38


consistent care, reduced

variation in care, reduced

revision rates and readmissions



A minimum level 2 high

dependency unit available

Ability to manage

complicated and

deteriorating patients safely

and effectively on site

minimising the need for

transfer




other health conditions

or disabilities which

might cause medical

complexity

Systems and processes in place

to effectively manage

deteriorating patients/those who

require more intensive treatment

including transfer to intensive

care

Early identification of patients

who are likely to require

additional medical support to

enable care plans to be

initiated.

Patients receiving the right

care are the right time

through immediate referral to

the most appropriate hospital

that meets their clinical need.

Robust pathways in place to

transfer patients to Intensive

care






might cause medical

complexity

Senior overnight medical cover

giving medical cover 24/7 on site

The needs of patients who

deteriorate unexpectedly or

who require more complex

intervention can be safely and

effectively managed without

transfer improving patient

experience






might cause medical

complexity

Rehabilitation services 7 days a

week

Providing effective

intervention, improving

experience and reducing

length of stay






might cause medical

complexity

Table 6 Service Model changes and impacts

12.1.2 PATHWAY CHANGES


NCL wide Multidisciplinary Team

working (MDT). Robust structures in

place to share clinical learning

and provide specialist advice and

support regarding individual

patients

Improving patient safety and

effectiveness leading to

reduced revision rates,

readmissions and decreased

length of stay






might cause medical

complexity and people

who have

undergone/are


39


undergoing gender

reassignment

Care co-ordinator roles in place to

support patients in navigating the

system and accessing the right

care and support at the right time

Improved patient experience

and effectiveness of care

resulting in decreased length

of stay and the risk of

readmission



especially those over the

age of 65, people with




Consistent referral pathways and

criteria

Equitable care that ensure all

patients across NCL receive

the same high quality access

to services

MEDIUM POSITIVE


NCL wide approach to pre- and

post-operative information and

patient education

Ensuring all patients receive

the same high quality

information and advice

MEDIUM POSITIVE


especially those over the

age of 65 and those with

disabilities

Standardise NCL wide pre-

operative assessment practices

and protocols

NCL wide assessment

practices will ensure clinical

and social issues are

identified early and needs

based care plans

implemented

MEDIUM/HIGHPOSITIVE


especially those with

disabilities and for

people who have

undergone/are

undergoing gender

reassignment

Surgeons will follow the patient

from base hospital to planned

orthopaedic surgery centre to

ensure there is consistency of care

Improving patient experience MEDIUM/HIGHPOSITIVE


especially those with

disabilities and for

people who have

undergone/are

undergoing gender

reassignment

Table 7 Pathway changes and impacts

As the table above shows, we estimate that there could be some negative impacts for some

groups in relation to the re-location of services, however, the intended outcomes of the re-

location of services (reduction of waiting times and fewer cancellations) are seen as highly

positive outcomes for all patients, including some specific scoped in groups; the availability of

space for carers to stay with patients at Chase Farm is also a high positive impact.

For all other proposed changes, we estimate there will be medium or high positive impacts for all

patients and have identified scoped-in groups where the impact is likely to be most beneficial.

DISCUSSION OF THE IMPACTS OF THE CHANGES

The service change points cluster under five headings: locations of care provision; changes to

reduce cancellations; changes to manage complicated and deteriorating patients;


40

rehabilitation services; and changes to improve the care pathway. Each will be discussed below

in relation to positive or negative benefits for particular scoped-in groups.

12.2.1 LOCATIONS OF CARE PROVISION

The service changes proposed will rationalise the locations where adults receive planned

orthopaedic surgery, and consolidate surgery requiring an overnight stay onto two sites.

In the past planned orthopaedic surgery for adults was available in ten locations across the NCL

patch. The new service model proposes two sites for inpatient care (i.e. procedures requiring an

overnight stay) and four sites for day surgery (i.e. procedures not requiring an overnight stay).

All patients would experience a significant improvement in their care and to achieve this, some

patients would have surgery in a different hospital in future, when compared to current

arrangements.

Day surgery: For example, shoulder, hand and foot surgery

● 360 patients a year who would currently go to UCLH would have their surgery at

Whittington Hospital instead.

● 80 patients a year, who would currently have NHS care in a private hospital, would over

time have their surgery at UCLH instead.

● 1020 patients a year, who would currently have NHS care in a private hospital, would

over time have their surgery at Chase Farm instead.

Overnight stay: For example, hip and knee surgery

● 400 patients who would currently go to North Mid. would have their surgery at Chase

Farm instead.

● 360 patients who would currently go to Whittington Hospital would have their surgery at

UCLH instead.

● 560 patients who would currently have NHS care in a private hospital, would over time

have their surgery at Chase Farm instead.

● 40 patients who currently have NHS care in a private hospital would over time have their

surgery at UCLH instead.

● 225 patients referred to the RNOH for non-specialist care could be suitable for treatment

at the Chase Farm instead.

● 75 patients referred to the RNOH for non-specialist care could be suitable for treatment

at UCLH instead.

Two things should be noted here: first, the patients enumerated above are future patients, not

people who would have to changes location part way through their care; second, for those

requiring inpatient care, generally, only one or two visits to the hospital where operations are

done are needed.


41

Travelling to a different location may have positive or negative impacts for patients, depending

on the start point for their journey and which partnership they choose for their care; for some

people journeys may be shorter or easier, but for others journeys could be more complex, more

costly or longer. Mott MacDonald’s work reports in detail the potential impacts of changes of

location and travel time for the scoped in groups18.

Mott MacDonald assessed the following potential impacts:

● Longer journey times – high likelihood, moderately adverse –increase in journey time

expected for the majority of residents across NCL, but likely to be around 15 minute

increase

● Availability of public transport – high likelihood for northern partnership (North

Middlesex/Royal Free London) with moderately adverse effects; medium likelihood for

southern partnership (UCLH/Whittington Health) with minor adverse effects

● Additional travel costs – high likelihood, moderate adverse effects, especially for more

deprived communities, those with long term conditions and some BAME groups

● Cost and availability of parking – medium likelihood, minor adverse effects

For a full description of methodology and discussion of the impacts of change, together with

suggested mitigations, please see Mott MacDonald’s report.

Mott MacDonald have produced the following demographic information about the people who

are most likely to be affected by the movement of care provision (see the Mott MacDonald

report on transport issues for an explanation of their methodology):

18 PLACEHOLDER for link to MM report


42

LSOA19s where patients would see a change from University College London Hospital London to Whittington Hospital for day case care

Area

Total

population

(2011)

Total

population

(2018)

Residents

aged 65

and over

Unpaid

carers

Residents

with a

LTHD

Black

residents

White

residents

Asian

residents

Turkish

residents

Residents

from

most

deprived

LSOA's

Residents from most

health and

disability deprived

LSOA's

Change

Area – Total 972,460 1,090,797 126,843 28,297 142,159 112,787 630,238 131,601 18,300 192,335 45,925

Change

Area - % - -

12% 3% 15% 12% 65% 14% 2% 18% 4%

Study area

– Total 1,911,320 2,103,079 260,756 58,371 280,247 236,318 1,216,368 271,588 41,885 371,783 61,756

Study Area -

% - -

12% 3% 15% 12% 64% 14% 2% 18% 3%

Table 8 Changes for day case care from UCLH to Whittington Hospital

Statistically, this change would not appear to affect any of the scoped in groups disproportionately.

19 A Lower Layer Super Output Area (LSOA) is a geographic area showing small area statistics.


43

LSOAs where patients would change from Whittington Hospital to University College London Hospital for inpatient care

Area

Total

population

(2011)

Total

population

(2018)

Residents

aged 65

and over

Unpaid

carers

Residents

with a

LTHD

Black

residents

White

residents

Asian

residents

Turkish

residents

Residents

from

most

deprived

LSOA's

Residents from most

health and

disability deprived

LSOA's

Change

Area - Total 519,418 571,474 65,387 15,114 75,921 66,709 340,956 59,413 13,263 122,735 33,796

Change

Area - % - -

11% 3% 15% 13% 66% 11% 3% 21% 6%

Study area

– Total 1,911,320 2,103,079 260,756 58,371 280,247 236,318 1,216,368 271,588 41,885 371,783 61,756

Study Area -

% - -

12% 3% 15% 12% 64% 14% 2% 18% 3%

Table 9 Changes for inpatient care from Whittington Hospital to UCLH

Statistically, the biggest effect of this change would be for residents living in the most deprived areas and those with the most health and

disability deprivation.


44

LSOAs where patients would change from North Middlesex University Hospital to Chase Farm Hospital for inpatient care

Area

Total

population

(2011)

Total

population

(2018)

Residents

aged 65

and over

Unpaid

carers

Residents

with a

LTHD

Black

residents

White

residents

Asian

residents

Turkish

residents

Residents

from

most

deprived

LSOA's

Residents from most

health and

disability deprived

LSOA's

Change

Area - Total 347,525 376,934 43,893 11,742 54,838 71,052 198,627 39,234 18,420 143,491 11,292

Change

Area - % - -

12% 3% 16% 20% 57% 11% 5% 38% 3%

Study area

– Total 1,911,320 2,103,079 260,756 58,371 280,247 236,318 1,216,368 271,588 41,885 371,783 61,756

Study area -

% - -

12% 3% 15% 12% 64% 14% 2% 18% 3%

Table 10 Changes for inpatient care from North Middlesex University Hospital to Chase Farm Hospital

Statistically, the biggest effect of this change would be for Black people, Turkish people and those affected with social deprivation.


45

We believe there are four specific scoped-in groups who are potentially impacted by a change

in the location of their care, depending upon the start-point for their journey and their choice of

partnership:

Disability

Although it might be expected that patients with mobility issues would be negatively affected by

changes in location if longer or more complex journeys to hospitals were necessary, in fact they

are more likely to be eligible for patient transport than some other groups, so any changes could

be mitigated for many members of this group. There is, however, further consideration of impact

necessary for those with a physical disability who may not access patient transport services.

For those choosing Chase Farm for inpatient care there could be benefits for people who have

carers, as provision could be made for carers to stay overnight, which is likely to reduce anxiety

and allow their carer to be involved in their day-to-day care. This provision is currently available

at UCLH, so the proposals would offer more choice for people with carers.

There could be negative impacts for people who might struggle in new environments, for

example, those with sensory impairments and people with learning difficulties. Some potential

mitigations, raised at the stakeholder workshop, will be discussed in the next chapter.

Carers

Longer, more complex or more costly journeys are likely to have high negative impacts on carers,

whether they are the patient or caring for someone who is a patient. For carers who are patients

finding cover whilst they attend appointments can be difficult, and potentially costly, so the

shortest time away from home is beneficial.

Socio-economic deprivation

For those affected by socio-economic deprivation more costly journeys would be problematic.

Some people, depending on whether they are claiming certain benefits, are able to claim back

taxi fares to appointments. However, having enough money to pay the fare and then claim

back could cause problems.

Ethnicity

Mott MacDonald’s analysis shows that Turkish people and Black people could be particularly

impacted by the movement of services from North Middlesex University Hospital to Chase Farm

because of the location where they are likely to live. The Travel Analysis report discusses this in

more detail.

12.2.2 CHANGES TO REDUCE CANCELLATIONS

Ring fenced beds for planned orthopaedic surgery and dedicated theatres for operations would

both have the effect of reducing cancellations of appointments, improving waiting times,

reducing infection rates and reducing revision rates and readmissions.

These service changes were seen to be beneficial for all patients, with positive benefits for the

following groups:


46

Disability and gender reassignment - medications

A particular benefit of reducing cancellations was identified for people whose condition requires

them to take regular medications. Some surgical procedures require patients to stop taking

medications for a specified time before going to hospital. If their operation is cancelled, they will

have to stop their medications a second time.

Disability - anxiety

Reductions in cancellations were identified as being particularly beneficial for people who might

be anxious about going to hospital for an operation, for example people with developmental

and learning difficulties, mental health problems and mental illnesses, and those with sensory

impairments, who might have worked with carers or others to go to hospital on a particular day.

Similarly, reductions in waiting times would also be beneficial for people in this category.

Carers - disruption

For carers who are patients making plans for care provision in their absence can be complex; a

cancellation of an operation would be very disruptive for them.

Socio-economic deprivation - costs

Cancellations could be costly for people affected by socio-economic deprivation, for example,

for people on zero-hours contracts. Reducing waiting times and cancellations is likely to be

highly beneficial for this group in terms of less loss of income and fewer wasted journeys.

12.2.3 CHANGES TO MANAGE COMPLICATED AND DETERIORATING PATIENTS

Having robust systems in place to manage complicated and deteriorating patients, including

having onsite HDU facilities in centres offering inpatient planned orthopaedic surgery and having

24/7 medical cover would be beneficial for all patients, particularly for those with underlying

medical conditions and disabilities.

Disability - planning

There are likely to be high positive impacts for people with long term conditions and complex co-

morbidities. People’s needs could be planned for and their conditions managed without the

need to transfer to another hospital if they deteriorate.

12.2.4 REHABILITATION SERVICES AVAILABLE 7 DAYS A WEEK

By providing rehabilitation services 7 days a week patient will be able to be mobilised quickly.

This is likely to reduce the length of stay in hospital and improve patient experience. Patients with

disabilities are likely to have high positive benefits.

Disability – reducing length of stay

For many people with disabilities, particularly those who might be anxious about being in hospital,

having rehabilitation services available 7 days a week is likely to help them to return home to a

less stressful environment more quickly.


47

12.2.5 CHANGES TO IMPROVE THE CARE PATHWAY

Six of the changes identified are designed to improve the care pathway for patients: NCL wide

Multidisciplinary Team working; care co-ordinators; patients seeing the same surgeon and/or

surgical team throughout their care; consistent referral pathways; standardised patient

education and information; a consistent approach to pre-operative assessment.

Whilst the changes to the care pathway are likely to improve the quality of care for all patients,

there are some groups for whom the impacts are likely to be medium or highly positive.

Disabilities

For people who have complex needs having consistency in the care pathway is likely to be

highly beneficial. Having robust learning structures in place is likely to enhance staff

understanding of patients’ potential needs, for example how to help patients with sensory

impairments or developmental difficulties. Care co-ordinators are likely to have high positive

impacts for those with disabilities by helping them to understand the system and how to navigate

it.

Adults over 65

This group of patients is likely to gain medium benefit from standardised patient information, so

that they understand what is going to happen and what they need to do to maximise the benefit

of their operation. Further, this group could also benefit from care co-ordinators helping them to

navigate the care pathway.

Gender reassignment

For people in this category, disclosure of their gender reassignment can be worrying. Having

consistency across the care pathway would be highly beneficial. MDTs could provide specialist

advice to colleagues; care co-ordinators could provide information for patients and being

assured that they would see the same surgical team throughout is likely to reduce anxiety and

improve patient experience.

Socio-economic deprivation

For people who might anxious about loss of earnings or the cost of journeys to and from hospital

care co-ordinators are likely to have a high positive impact if they can provide information about

what support is available.

Carers

When a carer is a patient there is likely to be anxiety about how they can ‘fit in’ pre-operative

assessments, surgery and post-operative recovery with as little disruption to their caring duties as

possible. Care co-ordinators could have a high positive impact by helping carers to understand

how long the process is likely take and what support is available to them.

The findings from this phase of the work will be used to help formulate consultation engagement

plans. During the consultation practical mitigations will be explored with the scoped in priority

groups.


48

13. CONCLUSIONS

The objective of this phase of the health inequalities and equality impact assessment was to

identify where changes to the provision of planned orthopaedic surgery for adults in NCL might

have positive or negative impacts on protected characteristic groups, carers and those affected

by socio-economic deprivation.

Overall, for all patients, there are likely to be positive impacts on patients’ health by reductions to

waiting times, having fewer cancellations, reducing infection rates and reducing revision rates

and readmissions.

The report has shown that generally the changes are likely to have positive impacts for all

patients, and for some scoped-in groups in particular.

There are some potentially negative impacts arising from changes to the location of the services

in future, however, there are also some positive impacts from the location changes.

RECOMMENDATIONS FROM THE INTEGRATED HEALTH INEQUALITIES AND

EQUALITY IMPACT ASSESSMENT FOR THE CONSULTATION PHASE

The work in this phase of the EIA was designed to feed into the consultation phase. The

consultation will involve engagement with residents across the catchment seeking to:

● Understand whether the options are supported and perceptions about benefits and

concerns

● Identify a schedule of mitigations to reduce any negative impacts identified.

In conducting the consultation, we recommend the following:

13.1.1 RECOMMENDATION 1 – FOCUS ON POSITIVE STEPS TO TACKLE INEQUALITY

Stakeholders should be invited to consider, critique and co-design current and planned

mitigations for negative impacts identified in this report.

A stakeholder workshop held to validate the scoped-in groups for this element of the health

inequalities and equality impact assessment suggested several mitigations. These could be used

to develop especially valuable insight if incorporated into discussion guides for deliberative

workshops and/or other qualitative approaches:

● Volunteers who can help people with sensory impairments to navigate hospitals,

particularly in sites which they are unused to

● For people who have sensory impairments, learning disabilities, autistic spectrum

disorders or anxiety, a visit to an unfamiliar site ahead of an appointment could be

arranged to allow them to become familiar with the environment

● Co-ordination between GP and learning disability nurses at hospitals would be helpful for

people with learning disabilities


49

● Ways to transfer information on support needs between GP and hospital, and different

hospitals in the partnership

● Improve training for hospital staff on how to find support for those who need it, and know

how to ask patients what care they need

● Ensure that patients know what their patient journey is likely to be, including which

hospitals they will visit, and how many appointments they are likely to have

● Ensuring that carers are involved when the person they care for is a patient

● Ensuring that patients know what help there is for them

● Ensuring patients and carers know that they can ask for changes to appointment or

surgery times to better fit their needs

● Planning procedures to best help people with long term conditions, for example putting

people with diabetes first on operating lists to cause least disruption to their medications

● For people with lower literacy levels using picture diagrams

● For those with little or no English, ensuring adequate interpreting services are available

● Training staff in basic British Sign Language

● Utilising the skills of staff who already work in our hospitals to draw on their language skills

● Support patient choice at referral so that they can choose the most convenient

partnership for the surgery they will require

Further work with stakeholders could identify more mitigations.

13.1.2 RECOMMENDATION 2 – PRIORITISING PEOPLE FOR WHOM EQUALITIES IMPACTS ARE LIKELY

TO BE HIGHEST

During the public consultation stage (which will commence in January 2020) the views of groups

and individuals should be sought to generate potential mitigations for specifically identified

negative impacts, and to ensure that potentially negative impacts have not been overlooked.

We would recommend that the following scoped-in groups are consulted:

● Carers, including:

Carers who might be patients themselves

Those who care for people who might be patients

Young people who care for a person who might be a patient

● People affected by socio-economic deprivation

● Black and minority ethnic communities, in particular the following groups, who are highly

represented in Haringey and where current patterns of provision suggest may be likely to

have surgery at a different site in future:

People from Turkish backgrounds

People from Black African and Black Caribbean backgrounds

● People who have had/are in the process of having gender reassignment surgery

● Previous patients who fall into any of the scoped-in groups discussed in this report.

We believe that by asking individuals, and groups representing the scoped-in groups, what

worked for them and where there could have been improvements a robust schedule of

mitigations can be created.


50

13.1.3 RECOMMENDATION 3 – TARGETED APPROACHES TO ENGAGEMENT WHERE NECESSARY

We also recognise that targeted approaches to engagement may be necessary to reach some

of these groups, and recommend that the following are considered:

● Telephone interviews for members of the groups who may find it difficult to attend

meetings and events and tend to be under-represented in face-to-face engagement

exercises, specifically:

o People with physical disabilities and access challenges

o Carers

● Engagement through national or regional representative bodies and/or trusted networks

of people where relatively small numbers of individuals sharing protected characteristics

are resident across the entire footprint, specifically:

o People who have had/are in the process of having gender reassignment

surgery.

13.1.4 RECOMMNEDATION 4 - ENSURING FOLLOW-THROUGH

We recommend the consultation evaluation report should contain discrete summaries of:

● The views of scoped in groups and communities especially those identified as priorities

(see Recommendations 2 and 3)

● The views on potential mitigations with a view to exploring their feasibility and practical

implementation with providers, including – but not limited to - those identified through this

EIA (see Recommendation 1).

RECOMMENDATIONS FROM THE MOTT MACDONALD TRAVEL ANALYSIS

For completeness, we include here some recommendations from the Mott MacDonald travel

analysis:

● Existing transport schemes which could help patients unable to attend hospital

appointments by public transport due to a medical condition should be more widely

promoted, including ensuring that GPs and other referrers have the right information to

support patients

● More generally, clearer information should be provided about transport options,

including public transport and car travel

● Care co-ordinators could support patients in working out travel and access issues

● Hospital sites could consider having rooms set aside for overnight accommodation for

those who have long or difficult journeys, or who have difficulty getting home, for

example, due to adverse weather conditions

● Consideration could be given to staggering admissions to reflect the distance patients

are travelling to hospitals

● Patients should be made aware that they can ask for appointment times to suit their

commitments and travel needs


51

● Hospital trusts, local councils and transport providers could work together to ensure that

their local strategies are joined up and promote local accessibility

● Trusts should consider whether there are any actions they could take to improve transport

for patients, for example, at Chase Farm there is a charity run minibus to pick patients up

from existing bus stops and take them to the main entrance

● A continuous review of accessibility through a travel plan should be considered,

including understanding current travel arrangements via patient engagement and

understanding best practice in other Trusts and hospitals

Fuller versions of the recommendations, travel time analysis and methodology can be found in

the Mott MacDonald report.

Documents

NLP Planned Orthopaedic Surgery for Adults · NLP Planned Orthopaedic Surgery for Adults - Health Inequalities and Equalities Impact Assessment 6 2. BACKGROUND North London Partners