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EQUALITY ANALYSIS AND ASSESSMENT OF OUTCOMES


Name of ‘activity’:

(Policy/strategy/procedures/services/projects/functions commissioning or decommissioning decision will be referred to as ‘activity’ throughout the document.)
INTEGRATED ORTHOPAEDIC, MSK, RHEUMATOLOGY & PAIN SERVICE
Date of commencing the assessment:

Date for completing the assessment: 23.9.13

Responsible Director/CCG Board Member:

Mark Youlton



Directorate/Team:

Acute commissioning



Assessment Lead:

Cathy Gardener



Contact Details:

01282 644877



ENGAGEMENT AND INVOLVEMENT

Which protected groups and other employees/staff networks do you intend to involve in the equality analysis?


  • East Lancashire Hospitals Trust

  • Other providers

  • GP’s / GP Minor Surgery DES/LES providers

  • Public Health

  • GP Participation Groups

  • Patient Advice Liaison Service (PALS)

  • NHS England

  • Monthly service review meetings

  • Patient Group meetings

  • Healthwatch

How will you involve people with protected groups in the decision making related to the policy development, commissioning decision or service review?
We will meet Quarterly with clinical leads, and service managers who will support the decision making process and sense check pathways and areas of redesign. Other third sector/ voluntary members will be involved at identified milestones throughout the project plan


  • The CCG will hold locality communication / engagement events.




  • Public involvement – Options of service delivery will be shared and views will be sought to inform the service specification




  • Patient focus group feedback analysis




IMPACT

Which groups does the policy or decision being made impact upon?

Service Users

x Yes

 No

Carers or family

x Yes

 No

General Public

x Yes

 No

CCG Staff

 Yes

 No

Partner organisations

x Yes

 No





How was the need for the ‘activity’ identified?


  • The CCG’s Integrated Strategic Plan 2013-18 sets out a strategic commitment to deliver more care in the community and in locations closer to patients’ homes.




  • The World Health Organisation (WHO) and European Bone and Joint Health Strategies Project identified:

    • MSK conditions are the most common reason for repeat consultations with a GP – up to 30% of primary care consultation

    • Up to 60% of people on long term sick leave cite MSK problems as a reason

    • 40% of people over 70 have osteoarthritis of the knee

    • It is estimated that 8-10 million people in the UK have arthritis – 1 million are adults under the age of 45

    • Low back pain is reported by about 80% of people at some time in their life




  • Musculoskeletal conditions are the second most common reason for claiming employment and support allowance in England and this is mirrored in the North West region.




  • Using the template provided by Parsons et al (2011), it is estimated that in Lancashire there are approximately 77,168 males and 109,029 females with musculoskeletal conditions (based on 2011 Census population).




  • PROMS demonstrates that a significant proportion of patients see little or no improvement post-surgery for joint replacement and would not have had surgery had they been fully aware of the outcomes prior to their surgery.




  • Musculoskeletal problems are expected to rise significantly between now and 2030 with the ageing population, increasing rates of obesity and low rates of physical activity. For example, the number of people with arthritis in the UK is expected to rise from 8.5 million to 17 million, causing an increased demand for joint replacement. (Ref: Arthritis Care (2011). Report. Understanding Arthritis




  • Commissioning intelligence from Advice & Navigation suggest that 17% of referrals that were intended for 2º care orthopaedic services could be managed in an alternative setting.




How is the activity meeting that need?

Community Integrated Assessment Service for MSK, Rheumatology and Chronic Pain Management team offers assessment, treatment and advice plus education to patients on self-management of their condition.


The team will work collaboratively with other primary and secondary care teams to ensure a streamlined, seamless service for patients.
The service provides a holistic approach to the management of chronic pain conditions, with the emphasis on providing support to enable patients to manage their long term condition.

What is the activity looking to achieve?
This option will involve decommissioning the MSK, Rheumatology and Pain Management services and re-commissioning a community integrated MSK, rheumatology and pain management service within a fixed budget. The new service provider will be given the option to sub-contract other providers on a prime contracting basis.

The provider will be expected to use economies of scale and reduction of inefficiencies in patient pathways to provide the service within a reduced financial envelope.





What are the aims and objectives?


  • The CCG will work within national guidance from Monitor and NHS England in regard to 'below' tariff' pricing. This will include working within the principles of the patients’ best interests, transparency and proactive engagement

  • Some procedures such as joint injections & carpal tunnel will be decommissioned from orthopaedic secondary care and will be provided in the new service or primary care.

  • The savings are based on efficiencies from Rheumatology and Pain Management in addition to the above reduction in day cases.

  • A percentage of these savings will be used by the provider to manage the increased in demand for the integrated service (joint injections/carpel tunnel/patients deflected from secondary care services) and additional costs associated with providing a comprehensive service in all five localities.

  • The service will be widely used by East Lancashire GPs as first point of all orthopaedic secondary care referrals to allow triage to take place.

  • As a consequence of the new service model it is anticipated that the demand for Orthopaedic referrals will reduce.




  • Full Orthopaedic/Rheumatology/Pain & MSK Management budget (minus agreed % to reflect efficiency gains) to one provider who may subcontract other service providers (eg Prime Contract Model)

  • Integrated pathways to support patient movement through the whole system

  • Allows for greater innovation, service improvements and economies of scale

  • Prevents providers competing for patients as it is whole system approach and not funded on an activity basis

  • Long term condition support and patient management in the community

  • Increase in the number of treatments available within the community

  • Provide full range of services within each locality, including the newly built Colne Heath Centre

  • Care provided by the most appropriate health professional

  • Community referrals to patient support groups and third sector organisations improve holistic support for patients


Services currently provided:

  • MSK service which is led by (GPwSI) providing a restricted range of services in the community at various health centres across East Lancashire

  • Comprehensive range of Consultant led services provided by ELHT in an Acute setting for Rheumatology, Orthopaedics and Physiotherapy

  • Community Physiotherapy service provided in a range of services across East Lancashire

  • MDT - Pain Management service provided by ELHT

EVIDENCE OF ANALYSIS

What Evidence have you considered as part of the Equality Analysis and Assessment of Outcomes?


  • All research evidence base references including nice guidance and publication – please give full reference




  • Department of Health Guidelines – MSK Services Framework cites best practice as an integrated MSK service with Rheumatology and Pain Management. This framework is evidence based and has been subject to substantial patient, clinician and stakeholder engagement.



National statistics:

The World Health Organisation (WHO) and European Bone and Joint Health Strategies Project identified:



  • MSK conditions are the most common reason for repeat consultations with a GP – up to 30% of primary care consultation

  • Up to 60% of people on long term sick leave cite MSK problems as a reason

  • 40% of people over 70 have osteoarthritis of the knee

  • It is estimated that 8-10 million people in the UK have arthritis – 1 million are adults under the age of 45

  • Low back pain is reported by about 80% of people at some time in their life




  • PROMS demonstrates that a significant proportion of patients see little or no improvement post-surgery for joint replacement and would not have had surgery had they been fully aware of the outcomes prior to their surgery.




  • Musculoskeletal problems are expected to rise significantly between now and 2030 with the ageing population, increasing rates of obesity and low rates of physical activity. For example, the number of people with arthritis in the UK is expected to rise from 8.5 million to 17 million, causing an increased demand for joint replacement.


Local population:

  • Using the template provided by Parsons et al (2011), it is estimated that in Lancashire there are approximately 77,168 males and 109,029 females with musculoskeletal conditions (based on 2011 Census population).

WHAT OUTCOMES ARE EXPECTED/DESIRED FROM THIS POLICY/PROPOSAL?

Who will benefit from this policy/proposal and in what way will they benefit?



  • Patients / Public Sector

  • CCG

  • Clinicians

  • Acute Trust




Does the policy/proposal explicitly involve the elimination of inequality, or the promotion of equality?)
The Integrated MSK, Rheumatology and Pain Management service aims to promote equality by delivering a multi-disciplinary service between GP’s, MSK and traditional secondary care led services demonstrates equity of access to protected groups.


What are the benefits to patients and Staff?

Patients

  • Integrated Care delivered closer to home for assessment and treatment improving access for patients.

  • Increase in range and level of activity and physical performance

  • Increase patient experience

  • Facilitation of well supported self-management for those with chronic musculoskeletal conditions

  • Patients are able to self-manage their condition

  • Improved patient quality of life, and return to work or normal social function where appropriate

  • Reduced waiting times

  • Improve patient outcomes


Clinicians

  • Improve staff skill mix in the community service

  • Reduce inappropriate referrals to secondary care services that can be seen and assessed within the community

  • Release limited secondary care resources for activity that only they can provide (more acute and complex diagnosis)

  • Improve GP satisfaction rates with MSK, Rheumatology and Chronic Pain services

  • Increase knowledge and understanding of managing MSK, Rheumatology and Chronic Pain conditions by primary practitioners

CCG

  • Integrated MSK, Rheumatology and Pain Management community service allowing greater flexibility to design pathways to improve quality outcomes and reduce inefficiencies.

  • Economies of scale – reduction in management costs

  • Flexible use of alternative contracting models to reduce costs in overall budget and increase value for money

  • Reduced waiting times for Community Care

  • Management of 2º Care demand reducing 18 week pressures and contract over-performance

  • Will provide a single point of access for MSK, Rheumatology and Pain Management referrals, ensuring patients are placed on the most appropriate clinical pathway

  • Greater use of primary care and the 3rd sector to promote self-help and provide more holistic support for patients

  • Better use of existing community estate (i.e. LIFT centres)

  • Increase in the number and types of treatments provided within the community/localities (including the new Colne health centre)

  • Care delivered closer to home for assessment and treatment improving access for patients




What targets/indicators will be used to measure these to provide assurance to the CCG and patients?


  • The service provider will conduct customer satisfaction surveys on a bi-annual basis

  • Patient and referrer feedback is reviewed and acted upon by the provider/s

  • Patients to participate in the friends and family test

  • The Provider will be required to deliver a performance framework relating to the service, designed to inform the CCG as the commissioner about the performance against the outcomes and KPIs.

  • Evaluation of evidence from the service to demonstrate future requirements.




HUMAN RIGHTS, PRIVACY IMPACT, COMMUNITY COHESION AND COST

Does the ‘activity’ raise any issues in relation to Human Rights as set out in the Human Rights Act 1998




If the decision removes or engages a person’s absolute right the policy/decision will need to be changed. Where it is a Limited or Qualified Right the decision needs to be proportional and legal. (State below your assessment)

Does not impact on any human rights



Have you carried out a Privacy Impact Assessment?


What were the findings of the privacy impact assessment when carried out: (For support please contact Information Governance).
We have considered a PIA and have come to the conclusion that it is not required as there would be no genuine risk to the privacy of the individual

Complete attached PIA


Does the ‘activity’ raise any issues for Community Cohesion?

If the policy positively impacts some groups and negatively impacts or overlooks other sections of the community, what effect will this have on the relationship between these groups? Please state how will you manage this relationship?
There are no obvious reasons to why Community Cohesion should not be integrated as service provision will continue to be provided in all localities


What is the overall cost of implementing the ‘activity’?

Please state: Cost & Source(s) of funding

Cost saving are anticipated from implementing this service


The CCG does not wish to disclose this information




Equality Analysis and Impact Assessment

Does the ‘activity’ have the potential to:

  • Have a positive impact (benefit) on any of the groups?

  • Have a negative impact / exclude / discriminate against any person or group?

  • Explain how this was identified? Evidence/ Consultation?

Group

Positive (Y/N)

Negative (Y/N)

Reasons for positive / negative impact – (Please include all evidence you have considered as part of your analysis e.g. population statistics, service user data broken down by equality group e.g. those undergoing liposuction in the last 12 months including ethnicity, gender, age, disability/long term conditions).

Age


Y

N

MSK conditions are the most common reason for repeat consultations with a GP – up to 30% of primary care consultation. Up to 60% of people on long term sick leave cite MSK problems as a reason. 40% of people over 70 have osteoarthritis of the knee and it is estimated that 8-10 million people in the UK have arthritis – 1 million are adults under the age of 45

Low back pain is reported by about 80% of people at some time in their life

Current evidence implies that older people are more susceptible to the experience of pain than any other sector of the population. National UK statistics report approximately 50 per cent of people aged 65 years and older are in some degree of pain or discomfort – nearly 5 million older people. The proportions for the over-75s increases to 56 per cent of men and 65 per cent of women. This equates to over 1 million men and nearly 2 million women, which is illustrative of the gender differences in pain across age.





Disability

Y

N


There will be a positive impact on this protected group. The specification for the new service will include requirement for Equality Act 2010 compliance and offer care closer to home.
Disabled users of the service will have communication needs and the need for BSL interpreters and information in different formats will be considered as part of this proposal.

Orthopaedic and MSK related conditions fall into disability therefore having a service which is accessible to more people means that this is a positive impact.






Marriage & Civil Partnership

N/A

N/A

Employment Only




Pregnancy and maternity

N/A

N/A


Looking at the data, there is nothing to suggest a negative impact. Due consideration is given to women who are pregnant and new mothers who are breastfeeding.


Race


Y

N

The service will take into account the particular needs of people from different ethnic and cultural backgrounds reflecting the diverse needs of people across East Lancashire as displayed in the table below.

Average Race Groups

Group

People

% Total

 

382359

 

White British

333264

87.16

White Irish

2294

0.60

White Other

5812

1.52

Mixed

3594

0.94

Asian/Asian British

32348

8.46

Black/Black British

688

0.18

Chinese

3824

1.00

Other

459

0.12

Musculoskeletal pain is reported more commonly by South Asians in the UK than by white Europeans. Rheumatic diseases vary in prevalence with different ethnic backgrounds eg Rheumatoid arthritis is less common in the Asian population, but systemic lupus erythematosus has a higher prevalence in the Asian and Afro-Caribbean population.

One of the most significant changes in the demography has been the increase in numbers of different ethnic minorities coming to live and work in the UK especially from Eastern European community’s i. e members of the Polish communities.


In the absence of routine or uniform gathering of ethnicity another source of information is use of requests for Interpreting Services. This gives an indication of the language needs of minority ethnic minorities and the statistics could be extrapolated for the purposes of the Equality Impact Assessment. They could indicate the level of demand for foreign language interpreters in the Dermatology services, inherently affected by the proposed reconfiguration of the service. We recognise that a need for an interpreter is not a proxy indicator for minority ethnic people, but only those who are not competent in English as a foreign language. This information could be used in the consultation process to engage with ethnic minority organisations to gather anecdotal or qualitative information to help inform the equality assessment.
The need for Interpretation and translation will need to be considered as part of this proposal


Religion or belief

Y

N


Due consideration will be given to sessions commissioning in line with religious and cultural needs (Friday prayer, Saturday Sabbath). Providers will have a responsibility to have due regard to equality target groups via the service specification


Sex


Y


N


National UK statistics report approximately 50 per cent of people aged 65 years and older are in some degree of pain or discomfort – nearly 5 million older people. The proportions for the over-75s increases to 56 per cent of men and 65 per cent of women. This equates to over 1 million men and nearly 2 million women, which is illustrative of the gender differences in pain across age.


Sexual orientation

Y

N


Discrimination and homophobia can have a significant impact on LGB people’s engagement with society and infrastructures in society. It also has a significant impact on how they are treated by some health care providers.

There is no local statistics available for this protected group.The IHS data in the survey period April 2011 to March 2012 indicate that:



  • 93.9 per cent of adults identified themselves as Heterosexual/Straight,

  • 1.1 per cent of the surveyed UK population, approximately 545,000 adults, identified themselves as Gay or Lesbian,

  • 0.4 per cent of the surveyed UK population, approximately 220,000 adults, identified themselves as Bisexual,

  • 0.3 per cent identified themselves as ‘Other’,

  • 3.6 per cent of adults stated ‘Don’t know’ or refused to answer the question,

0.6 per cent of respondents provided ‘No response’ to the question

Gender reassignment

Y

N


Discrimination and homophobia can have a significant impact on LGB people’s engagement with society and infrastructures in society. It also has a significant impact on how they are treated by some health care providers. Evidence from stonewall.org.uk

All staff members will adhere to company policy and will have undertaken the relevant Equality and Diversity training.

From the latest CCG report (Dec13 publication) and results from 5915 GP patient surveys, within East Lancashire there are 5508 heterosexual/straight people, 66 Gay/Lesbians, 43 Bi-sexual, 36 other and 262 preferred not to say.


Carers


Y

N

The service will promote equality of opportunity for all adults and those with caring responsibilities by offering flexibility and access for appointments.

From the CCG December 13 GP Patient Survey publication, the following category:



Look after / provide help or support to family, friends, neighbours or others for long-term physical or mental ill health / problems related to old age (see table below)



Look after / provide help or support - total responses

No

Yes, 1-9 hours a week

Yes, 10-19 hours a week

Yes, 20-34 hours a week

Yes, 35-49 hours a week

Yes, 50+ hours a week

895,501

729,937

95,192

19,665

11,886

8,159

30,661

5,871

4,644

705

167

81

40

233





Deprived Communities

Y



N

The service will promote equality of opportunity for all adults

Vulnerable Groups e.g. Homeless, Sex Workers, ex-military







Table 1 Households accepted as homeless and in priority need, April 2012 to March 2013 LCC

 

Households accepted as homeless

Number per 1,000 households

Rank of 326 authorities in England (by per 1,000 households)*

Burnley

61

1.69

139

Hyndburn

8

0.24

305

Pendle

22

0.58

282

Ribble Valley

16

0.64

274

Rossendale

15

0.52

288




Other

(please state)







N/A

Risk Assessment

Risk Score:


if moderate or high (please state what will be done and how this mitigates the risk):




Actions required to reduce/eliminate the negative impact

Resources required*

(see guidance note below)



Who will lead on action?

Target completion date

Low


No major change in policy / Continue policy













Moderate


Adjust policy















High


Stop and reconsider policy














* ‘resources required’ is asking for a summary of the costs that are needed to implement the changes to mitigate the negative impacts identified.

Monitoring and Review

Please describe briefly, how the action plan will be monitored?

The action plan will be monitored in line with the progress of the pilot, regular reviews will take place within the monthly project meetings




Date of the next review of the Equality Analysis/Action Plan?

July 2014



Which CCG Committee will be responsible for Monitoring?

East Lancashire CCG








Signature of person completing the impact assessment:
Jayne Tebbey / Donna Parker



Signature of Competent Equality Officer:

Date Completed:
On-going


Date received:


Date Reviewed:


Date Signed Off by CCG Committee:



Equality Risk Assessment - Severity score

Descriptor

1

2

3

4

5

Insignificant

Minor

Moderate

Major

Catastrophic

Objectives / Projects

Project plan and objectives are fully inclusive of all protected groups impacted up – an equality analysis has been carried out

Project milestones include reviews of the equality analysis and evidence of engagement with protected groups

Equality analysis done but minimal evidence of programme of review or action plan to mitigate negative impacts

Equality analysis done but no evidence of programme of review or action plan to mitigate negative impacts

There has been no full equality analysis carried out – risks not mitigated through action plan

Patient Experience

Unsatisfactory client/patient experience not directly related to patient care

Unsatisfactory client/patient experience – readily resolvable

Mismanagement of client/patient care

Serious mismanagement of client/patient care

Totally unsatisfactory client/patient outcome or experience

Complaints

Locally resolved complaint relevant to equality or human rights

Justified complaint peripheral to equality and human rights

Below excess claim. Justified complaint involving indirect discrimination or breach of a person’s qualified or limited human rights

Claim above excess level. Multiple justified complaints involving equality discrimination or breach of a person’s absolute human rights

Multiple claims or single major claim

Staffing and Competence

100% of staff have received training in Equality and Human Rights and feel competent to deliver EDHR in relation to their job role

75% of staff have received training in Equality and Human Rights and feel competent to deliver EDHR in relation to their job role

50% of staff have received training in Equality and Human Rights and feel competent to deliver EDHR in relation to their job role

25% of staff have received training in Equality and Human Rights and feel competent to deliver EDHR in relation to their job role

Non-delivery of key objective / service due to lack of staff. Loss of key staff. Critical error due to insufficient training
Staff not had any training in Equality and Human Rights

Potential cost

Up to £10K

£10,000 - £25,000

£0.25m - £0.5m

£0.5m - £1m

£1m plus

Inspection / Audit

Minor recommendations. Minor non-compliance with standards

Recommendations made. Non-compliance with standards

Reduced rating. Challenging recommendations. Non-compliance with core standards

Enforcement action. Low rating. Critical report. Major non-compliance with core standards

Prosecution. Zero rating. Severely critical report

Adverse Publicity / Reputation

Contained within the organisation. Rumours

Local media – short term. Minor effect on staff morale

Local media – long term. Significant effect on staff morale

National media up to 3 days

National media >3 days. MP concerns (Questions in the House)

2 – Likelihood score





1

2

3

4

5

Descriptor

Rare

Unlikely

Possible

Likely

Almost Certain

Frequency

Not expected to occur for years

Expected to occur at least annually

Expected to occur at least monthly

Expected to occur at least weekly

Expected to occur at least daily

Probability

<1%

1-5%

6-20%

21-50%

>50%

Will only occur in exceptional circumstances

Unlikely to occur

Reasonable chance of occurring

Likely to occur

More likely to occur than not


1 (severity) x 2 (likelihood) = total risk score and rating


Likelihood

Severity

1

2

3

4

5

1

1

Low

2

Low

3

Low

4

Moderate

5

Moderate

2

2

Low

4

Moderate

6

Moderate

8

Significant

10

Significant

3

3

Low

6

Moderate

9

Significant

12

Significant

15

High

4

4

Moderate

8

Significant

12

Significant

16

High

20

High

5

5

Moderate

10

Significant

15

High

20

High

25

High


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