Item for:- Decision X Recommendation

Information

AGENDA ITEM NO: 6.0. Primary Care Commissioning Committee - 18 February Meeting Title/Date: 2020 Options Appraisal - Askam-in-Furness General Medical Report Title: Services CCG Primary Care Date of Paper Prepared By: February 2020 Commissioning Team Paper: Responsible Executive Sponsor: Hilary Fordham Kate Hudson Manager: Committees where Paper Draft paper provided to Clinical Executive Committee on Previously Presented: 11 February 2020. Background Paper(s): N/A.

Summary of Report: The Primary Care Commissioning Committee is responsible for determining how general medical services are provided to the population of Morecambe Bay including the population of Askam and Ireleth.

Dr Jain has provided written confirmation of his retirement which will terminate the GMS contract for Askam Practice with effect from 31 March 2020. Attached are:-

1) Options Appraisal in respect of the future provision of services to patients registered at the practice.

2) Health Needs Analysis.

3) Equality Impact Assessment. Recommendation(s): The Primary Care Commissioning Committee is required to consider the attached papers and determine which of the two options delivers the most sustainable long term option for the relevant population:-

 Option 1) List Dispersal.

 Option 2) Procurement. Please Select Y/N Identified Risks:  Concerns have been raised in Y (Record related Assurance relation to transport links to Framework or Risk Register surrounding practices if the Askam reference number) Practice was to close.

 Potential for financial and reputational risks if a procurement was undertaken and subsequently failed.

 Financial impact in relation to ‘Caretaking’ arrangements for a period between 3 and 8 months as this exceeds the current spend for the contract.

 Premises for ‘caretaking’ period and any future contractor are not currently secured. Impact Assessment: Attached. Y (Including Health, Equality, Diversity and Human Rights) Strategic Objective(s) Please Supported by this Paper: Select (X) Better Health - improve population health and wellbeing and reduce X health inequalities Better Care - improve individual outcomes, quality and experience of care X

Delivered Sustainably - create an environment for motivated, happy staff and achieve our control total Please Contact: Kate Hudson Head of Primary Care [email protected]

MORECAMBE BAY CCG PRIMARY CARE COMMISSIONING COMMITTEE

RESIGNATION OF DR JAIN ASKAM IN FURNESS (A82621)

OPTIONS APPRAISAL

1. INTRODUCTION

1.1 Dr Jain is the sole holder of a General Medical Services (GMS) contract for the provision of Essential, Additional and Enhanced services to a registered population of 1,539 as at 01 January 2020 (*this has reduced to 1490 as at 11 February 2020). Services are currently provided from the Askam practice at 2 Parklands, Askam in Furness. The practice is part of the Mid Furness PCN which includes Duddon Valley Medical Practice and the two practices based within Ulverston Health Centre (Dr Murray & Partners and Dr Johnston & Partners).

1.2 On 31 December 2019, Dr Jain contacted the CCG and confirmed that he wished to submit his notice of resignation from the GMS contract to be effective from 31 March 2020.

1.3 The CCG provided written confirmation of acceptance of Dr Jain’s resignation and initiated the development of a local Health Needs Analysis. The CCG also began a programme of patient and stakeholder engagement.

1.4 This paper sets out options for the future commissioning of primary medical services to meet the needs of the registered population.

*source data from the Askam Practice clinical system. Formal February list size to be confirmed when available.

2. BACKGROUND

2.1 In August 2019 Morecambe Bay CCG was notified that Dr Jain had been suspended from the National Performers List for a period of 6 months and that consequently Dr Jain would not be able to provide general medical services to patients personally. This process is managed by NHS England and any decisions regarding Dr Jain’s future inclusion in the Performers List will be taken by NHS England.

2.2 As the sole signatory to the GMS contract, Dr Jain was required to ensure that services continued to be provided to patients even though he was not able to personally deliver these. Consequently, Dr Jain has employed doctors to work at the practice on a Locum basis since August 2019. Some of the Locums have been local GP colleagues, whilst others have been engaged through a Locum Agency.

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2.3 Separate reports have been presented to the Committee regarding the on-going monitoring of Dr Jain’s contractual responsibilities in ensuring the continuity of primary medical services.

2.4 The practice staff remain employed by Dr Jain and are currently working in the practice. This includes the dispensing staff and, therefore, the dispensary is operating. The Committee should note that governance of the dispensing contract lies with NHS England although the CCG understands that Dr Jain has complied with the relevant guidance in this respect.

2.5 In accordance with paragraph 26.6 of the GMS contract, a sole General Practitioner is required to provide 3 months’ notice of his intention to resign from the contract. Dr Jain submitted his notice on 31 December 2019 with an end date of 31 March 2020 and, therefore, has satisfied his contractual obligation.

“Where the Contractor gives notice to the Board under clause 26.6.1, the Contract terminates three months after the date on which the notice was given (“the termination date”), unless the termination date does not fall on the last calendar day of a month, in which case the Contract terminates instead on the last calendar day of the month in which the termination date falls.”

2.6 NHS England is responsible for the Commissioning and Contracting of dispensary services and they manage applications from community pharmacies to open new premises through the ‘Market Entry’ regulations and guidance. However, Cumbria County Council’s Health and Wellbeing Board is responsible for reviewing the pharmaceutical service provision in Cumbria and identifying where there are additional needs or gaps; the relevant document produced is called the Pharmaceutical Needs Assessment (PNA). The PNA also forms part of the market entry decision making process; the PNA published in 20171 shows that:

“ Conclusions and Recommendations for Barrow in Furness District “The HWB considered the opening times and ease of access to determine that the community pharmacies and dispensing doctors in the HWB area meet the needs of the Barrow-in-Furness district population for the provision and access to pharmaceutical services.”

Whilst a new provider, if sourced via open procurement, would be able to apply for a new dispensary contract this would not be in place during the caretaking period. There is the ability for any general medical provider to issue emergency medications to patients if medically required but this would not enable the caretaker provider to dispense routine or controlled medications to patients throughout the caretaking period.

3. CURRENT SITUATION

3.1 Following receipt of Dr Jain’s resignation from the GMS contract, there are two key actions that the CCG needed to undertake:

 Notify registered patients of Dr Jain’s decision; and

1 https://www.cumbria.gov.uk/eLibrary/Content/Internet/536/671/4674/17217/17220/43186155451.pdf ______

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 Decide the way in which services would be provided to patients in the future.

3.2 Practice Staff

The staff at the Askam Practice have been integral in the maintaining of service provision for patients during Dr Jain’s suspension and have been commended by the CCG for their commitment and dedication.

3.3 Patient Engagement

A letter was sent to patients (addressed to Head of Household) confirming that Dr Jain had given notice of his resignation from the contract with effect from 31 March 2020. Enclosed with this letter was a questionnaire for patients to complete; the questionnaire comprised a brief set of questions around issues that were felt to be of importance to patients, and helpful to the CCG in terms of deciding how services should be provided in the future. Additional copies of the questionnaire were available from the practice at Askam as well as being available on-line via the CCG website. In total 446 completed questionnaires were received, this represents 29% of the registered patients at the surgery.

3.4 A series of four face-to-face patient engagement events were held at Askam Surgery, with a mix of times during the day and in the evening across Tuesday, Wednesday and Thursday. Approximately 150 patients attended these events which represents approximately 10% of the registered patients at the surgery.

3.5 Further detail in relation to the outcome of the patient engagement exercises is contained within the Health Needs Analysis document which accompanies this paper. However, the main themes from these events were:

 Lack of public transport: Patients were concerned that the lack of public transport meant that it could be extremely difficult for patients with limited mobility to travel to surrounding practices. Whilst the nearest surgery was at Dalton, patients were concerned that there was no direct train or bus service to Dalton. The cost of taxi journeys was a concern to a number of patients, specifically those on a limited income. Local taxi charges have been obtained and range from £10 for a one way journey to Dalton to £15 for a one way journey to Barrow2.

 Lack of pharmacy provision in Askam: Patients were concerned that without the GP practice there was no access to medicines without travelling to Dalton, Barrow or Ulverston. A number of Pharmacies are available in surrounding areas and are described in section 6 of the Health Needs Analysis.

 Lack of available places at local surgeries: Some patients reported that they had tried to register at alternative practices without success as they had been told that the practices were full. At the engagement events the CCG confirmed that all practices within Morecambe Bay CCG do have open lists and are therefore required to register new patients. Patients were also assured that the CCG would work with local practices to ensure that sufficient capacity is available at local practices should the decision be taken to disperse the list. Engagement with local practices has been undertaken and is included in section 7.4 of the Health Needs Analysis.

2 Verbally obtained approximate journey quotes from Acacia Taxis. ______

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A number of patients provided additional comments on their surveys. All of these comments have been captured verbatim and collated into one document. This document has been made available to Primary Care Commissioning Committee members prior to the Committee meeting.

 Preference for Drop-in Session: Patients reported the present system of ‘open access’ (ie no set appointments) worked well and would be preferable for the future.

Engagement with local practices

3.6 There are eleven GP practices within a 7.5 mile radius of the Askam Practice site. The travel time to these practices by car is between 7 and 15 minutes (a breakdown of distance and travel times by practice is provided within the Health Needs Analysis in section 5.

3.7 The CCG attended a meeting of the local Primary Care Network in Mid Furness and discussed the options in relation to the future of the Askam Practice with the surrounding GP practices. The feedback from Mid Furness PCN is included within the Health Needs Analysis in section 7.6.

3.8 A short questionnaire was sent to local practices within the Mid Furness and Barrow & Millom Primary Care Networks asking for views on the future provision of services, specifically the implications for their practices if the Askam patient list was dispersed or if a procurement exercise was undertaken.

3.9 Further detail in relation to the outcome of engagement with local practices is contained in the Health Needs Analysis document accompanying this paper. The overall responses from practices showed a 60:40 split demonstrating a preference of procuring a replacement practice. This contrasted with the strong view of the most local Primary Care Network that the Askam practice is contained within. None of the practice responses gave an indication that registering additional patients would present a significant problem. Two practices did indicate that they would be willing to be a ‘chosen provider’ for all Askam patients should the decision be made to disperse the list.

Market Engagement

3.10 As sourcing an alternative provider for the GMS contract at Askam in Furness is an option, the CCG took the decision to engage with the market in order to understand whether any alternative providers may be interested in competing for the contract.

3.11 Consequently, a market engagement exercise was undertaken through the production of a ‘Request For Information’, i.e. the advertisement of a potential contract. This was advertised through the Official Journal of the European Union as well as through ‘Contracts Finder’ (a national procurement portal) and was available for a period of 2 weeks. In accordance with NHS England’s Policy, this process is managed by North East Commissioning Support Unit (NECS).

3.12 The RFI will close on 13 February 2020; the number of completed documents returned via this process will be presented at the Primary Care Commissioning Committee members in the form of a summary report from NECS. This report will be provided to Committee members for consideration prior to the Committee meeting. It ______

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should be noted, however, that this market testing exercise does not form part of the formal procurement process and whilst this demonstrates the potential interest from the wider market, it cannot be guaranteed that these organisations would compete in a formal procurement exercise.

4. OPTIONS AVAILABLE

4.0 It is important to note that irrespective of the decision made in relation to the options presented in this paper, the following services will remain:

 Out of Hours Access to General Medical Services  Access to home visits for housebound patients  District nursing services  Community Services  Urgent Care/A&E Service

4.1 In respect of the future provision of services, there are two main options:

Option 1: Dispersal of the patient list Option 2: Undertake a procurement exercise

Option 1: Dispersal of the Patient List

4.2 The dispersal of the patient list would mean that patients would be asked to register with an alternative GP practice and the current practice at Askam in Furness would close. The process by which this would be achieved is set out in NHS England’s Primary Medical Care, Policy Guidance Manual. There are a number of steps involved in this process, Table 1 below sets out the key steps to be undertaken to disperse the list.

Table 1 - List Dispersal Steps

STAGE ACTION Pre-dispersal Obtain list of vulnerable patients from Askam Surgery Pre-dispersal Liaise with local practices to: i. advise of dispersal and need to accept registrations ii. understand any significant barriers practices might have in terms of registering additional patients Start of dispersal Write to all patients setting out details of local practices and period and asking patients to register with alternative practice. throughout NB: At least 2 letters should be sent to patients over the dispersal period dispersal period in order to ensure that all patients register with an alternative practice. A third letter should be sent to anyone remaining on the list at the end of the process (see below) Throughout Monitor the number of patients registered with Askam Surgery dispersal period to ensure this decreases over dispersal period Throughout Liaise with NHS England to ensure that patients identified as dispersal period vulnerable are registered with an appropriate alternative practice

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STAGE ACTION End of dispersal Liaise with NHS England to determine whether any patients process need to be assigned3 to a practice and write to relevant patients to notify them of the assignment NB: List dispersal does not override the right of patients to choose which practice they wish to register with and any patients who are assigned to a practice must be reminded that they have the option of changing GP practice. End of dispersal Manage closedown of GP clinical system and transfer of NHS process assets (medical records etc)

4.3 The above table is not exhaustive; however a detailed draft dispersal plan has been prepared as a precautionary measure in case this option is progressed.

4.4 Should the decision be taken to disperse the patient list, there are a number of matters to be considered; these are:

4.4.1 Date of dispersal / Caretaking arrangements: The list dispersal process can take some months to complete as patients need to be given sufficient time to find an alternative GP practice. Consequently it may be necessary for the practice to remain open for a short period of time after 31 March 2020 so that patients continue to have access to general medical services whilst the dispersal is achieved. Whilst there are no set timescales within the Manual, this is likely to take up to 3 months to complete. Furthermore, guidance from Primary Care Support England states that it takes between 1 and 3 months for the practice to be closed on the NHAIS4 system.

In this scenario, the CCG would need to appoint a ‘Caretaker’ to manage the practice for the 3 month period. This could be an Out of Hours provider or a local GP practice. It should be noted that this type of contracting arrangement often attracts a higher rate of reimbursement than GMS equivalent funding albeit on a temporary basis.

This poses a potential financial risk to the CCG as the cost of caretaking cover may exceed the current monthly costs for the Askam practice contract. Please see Section 5, table 2 within this document for current costs. Whilst exact costs of caretaking cover are not currently available it is anticipated that it would be extremely unlikely for this to exceed more than 1.75 times of the current monthly contractual value for a period of 3 months (maximum risk anticipated to be £41,820 above current expenditure).

4.4.2 Premises: Dr Jain owns the current premise and has confirmed that he will not lease the premises on a long term basis. However, if caretaking arrangements were to be made, the CCG would need to approach Dr Jain to discuss whether continued use of the building was an option. A request has been made to Dr Jain for agreement to a short term lease arrangement but to date no response has been received.

3 An assignment is where a patient is automatically placed with a practice to ensure continuity of care 4 This is the national suite of software which manages patient registration processes and also is used for payment purposes ______

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4.4.3 Open Practice Lists / Closed Practice Lists: Currently all local practices have ‘open’ lists and, therefore, are required to register new patients provided that the patient lives within the practice boundary. The CCG would need to enter into discussions with local practices, prior to the start of the dispersal process; regarding the impact of registering additional patients would have on the current level of service, this process has already begun, please refer to Practice Engagement section of the Health Needs Analysis. A practice can only refuse to register new patients if permission has been given for the patient list to be ‘closed’. There are currently no practices within Morecambe Bay CCG with closed lists and no new applications for list closure have been received to date.

4.4.4 Practice Staff: In the event of a list dispersal the surgery would close and the currently employed staff would be subject to redundancy. The staff are employed by the Askam Practice and Dr Jain would be responsible for any redundancy costs.

Option 2: Undertake a Procurement Exercise

4.5 As explained previously, the GMS contract ends on 31 March 2020 as Dr Jain is the sole signatory to the contract. In order to continue the provision of primary medical services in the Askam area, a new contract would need to be awarded to a new provider through an open procurement exercise.

4.6 It should be noted, however, that in line with procurement legislation, it is not possible to offer a new GMS contract and all new contracts must be Alternative Provider Medical Services (APMS) contracts. The main differences are:

 Length of contract: All APMS contracts must have an end date whereas GMS contracts are in perpetuity and have no end date;

 Price: GMS contracts are funded at a nationally agreed rate whereas APMS contract funding is determined by the Commissioner; and

 Contracting party: A wide range of providers are able to hold an APMS contact unlike the rules in respect of a GMS contract.

4.7 Consequently, the CCG would need to determine the above factors in relation to the contract to be procured for Askam. Whilst the funding for this would be determined by the CCG, it would be usual for this contract to be offered at GMS equivalent funding levels. The RFI document published (as explained in paragraph 3.11 above) was on the basis of the contract being funded at GMS equivalent rates with the opportunity to earn additional income through the Quality and Outcomes Framework (QOF), directed enhanced services and local enhanced services (see Section 5 below).

4.8 The procurement would be advertised on the open market through the Official Journal of the European Union (OJEU) and on the procurement portal. Interested parties would be invited to submit tenders for the contract, which would be evaluated by the CCG, in order for a successful bidder to be appointed.

4.9 Under procurement rules it is not possible to advertise the contract as a branch surgery of an existing contract. Therefore, the advertisement for the contract would

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specify that bidders would need to meet the requirements of the contract and be open for the full contractual core hours. Currently, the practice closes on Wednesday afternoons although Dr Jain did make arrangements to treat any patients in urgent need.

4.10 Should the decision be made to procure a detailed procurement plan would be required. A draft plan has been prepared as a precautionary measure in case this option is progressed. If a procurement was to take place there are a number of matters that would need to be considered, these are:

4.10.1 Date of Procurement / Caretaking arrangements: The procurement process for a contract of this size usually takes between 6 and 8 months to complete. There would be insufficient time to complete this process prior to the end of the current contract. Consequently if procurement was progressed the CCG would be required to arrange caretaking cover from 1st April to December 2020.

The CCG have investigated potential caretaking arrangements and have identified a range of costs. It is anticipated that the maximum cost of caretaking would be approximately 1.75 times the current contractual cost (maximum financial risk of caretaking anticipated to be £111,522 above current expenditure based on 8 months caretaking. Important to note that this does not take into account any additional expenditure for potential alternative premises costs over and above current notional rent payments).

4.10.2 Premises: Dr Jain owns the current premise and has confirmed that he will not lease the premises on a long term basis. However, if caretaking arrangements were to be made, the CCG would need to approach Dr Jain to discuss whether continued use of the building was an option. A request has been made to Dr Jain for agreement to a medium term lease arrangement but to date no response has been received.

Interested bidders would be asked to source premises from which services would be provided as Dr Jain owns the current premises. The CCG would not intervene between Dr Jain and interested bidders, as this would be a private matter between the two parties. If a bidder chose not to, or was unable to, purchase the premises from Dr Jain, the responsibility for sourcing new premises would remain the bidder’s and again the only involvement of the CCG and NHS England would be to ensure that the premises were fit for purpose and represented value for money.

Alternative premises/locations may be available within the local areas of Askam and Ireleth but these will not be currently used as, or fit for purpose as, a GP Surgery. Any applications for change of use of a premise could require an application process to Barrow Borough Council’s planning department, the timescales for approval of such requests can take up to 8 weeks. Following any successful application for a premises ‘change of use’ an additional period of conversion/re-purposing of the premise would be required. This may exceed the remaining time left within the current contract.

4.10.3 Practice Staff: If a procurement process was undertaken and successfully completed the currently employed staff would be subject to TUPE and would transfer into a new provider organisation.

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5. FINANCE

5.1 Table 2 below provides financial breakdown of the income for a surgery with a registered list size and similar premise to the Askam surgery. It should be noted that income / expenditure in relation to the dispensing service is not part of the contractual payments.

Table 2 – Contract Payments Monthly Annual Payments Payments Global Sum £13,272 £159,264 MPIG - - £1,500 £18,000 Directed Enhanced Services (approximate (approximate (commissioned through NHS England / figure dependent figure dependent Improvement) upon activity) on activity) Local Enhanced Services £207 £2,484 (commissioned through MBCCG) Quality Improvement Scheme (QIS) £657 £11,256 £20,589 (includes annual QOF £1,201 (aspiration) achievement payment) Notional Rent £1,750 £21,000 Rates (reimbursed) - - Approximate Approximate Monthly Total Annual Total £18,587* £232,593* [source: NHS England / MBCCG] *Totals are approximate and are dependent upon actual contract delivery for enhanced elements.

Dispersal

5.2 If it is agreed that the patient list should be dispersed, practices registering new patients will receive a ‘new patient registration fee’ which is equivalent to an additional 46% of the annual global sum figure. This fee is payable in the first year only, the Statement of Financial Entitlement (Annex B) confirms this as follows:

“Analysis of the workload implications revealed 40 – 50% more workload, as measured by aggregate consultation times, within the first year of registration. An average uplift factor, of 1.46, will be applied through the formula in respect of all new registrants in their first year of registration.”

5.3 For 2019/20, the global sum per patient per annum is £89.88, the increase in respect of new patients will, therefore, mean an additional £41.34 per patient per annum.

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Procurement Exercise

5.4 As said in paragraph 4.7 above, the CCG would need to determine the value of the APMS contract if it was agreed a procurement exercise should be undertaken. It is usual for the contract value to be at GMS equivalent funding. This would mean that the successful bidder would receive a contract value equivalent to the global sum figure shown in Table 2 above with the option of earning additional income through QOF and the provision of enhanced services.

5.5 The cost of undertaking a procurement exercise is £21,296; this is funded by NHS England through a contract held with NECS and would not have a financial impact upon the CCG.

5.6 It is likely that any new provider taking on a general medical services contract would request some form of time limited transition funding to enable the set-up of the new service. This transition funding is usually detailed within a bidder’s submitted tender documentation during a full procurement process and therefore is not available at present. Any transition funding requested during a procurement process would be assessed by the CCG in terms of value for money but this funding would be a cost pressure upon the CCG as it would be likely to exceed the current expenditure for the practice for a short period at the beginning of the contract.

5.7 If a procurement process was undertaken but was unsuccessful the Primary Care Commissioning Committee would need to reconsider the options outlined within this paper, in this scenario list dispersal would be the likely outcome.

5.8 The below table provides summary of financial impact of the options: Option 1 – List Option 2 – Procurement Dispersal Year 1 £41,820 (anticipated cost £111,522 (anticipated cost of of caretaking for 3 caretaking for 8 months) months) £232,593 (standard contractual £73,261 (new patient payments) registration fee) £232,593 (standard contractual payments) £344,115 total anticipated costs* £347,674 total anticipated *does not include any additional costs for: cost  Development of an alternative premise (if required)  Any increase in notional rent that may be applicable for new premise (if requried)  Any transition or start up funding requested by the new provider Year 2 onwards £211,593* (standard £232,593* (standard contractual contractual payments for payments) registered population, dispersed within global sum, amongst practices where patients chose to register) *does not include any additional costs for *notional rent of £21,000 no longer increased notional rent (if required) payable. ______

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Caretaking Costs

5.9 Anticipated costs for caretaking in the event of List Dispersal are included under section 4.4.1 and anticipated costs for caretaking in the event of procurement are included under section 4.10.1.

6. HEALTH NEEDS ANALYSIS

6.1 The full Health Needs Analysis has been included within this document but the following considerations have been identified:

6.1.1 The number of residents in Askam and Ireleth is 3,280; the number of registered patients at the practice is 1,539 (as at 01 January 2020) which is less than half of the resident population (47%). The average number of patients per whole time equivalent GP in Morecambe Bay CCG is 1,571 [source: CSU Business Intelligence Team]. Nationally, the average number of WTE GPs per 1,000 patients is 0.58.

6.1.2 The CCG is aware that the number of patients registered with the surgery is reducing with the most recent registered list size being 1490 as at 11th February 2020. This number has been provided by the staff at Askam Surgery based upon their EMIS clinical system. Formal list size for February 2020 will be available to the CCG on 14th February 2020. This could suggest that the numbers of registered patients, which to a large extent determines the financial income for a surgery, may not be high enough to ensure that the contract is sufficiently financially attractive to new providers.

6.1.3 The transport for the local area is limited with no public bus service and a community bus being available for only one day per week (Wednesday). A train service is available but patients with limited or restricted mobility may struggle to walk to and from the train stations. Taxi services are available but costs of return journeys to local GP surgeries in Dalton and Barrow are approximately £20-30. Approximately 44% of the population of Dalton North have access to a car but we are unsure how this translates to the registered population of the Askam Surgery. The CCG have been unable to obtain data confirming the number of registered patients with restricted mobility from the Askam practice clinical system.

6.1.4 Whilst the Health Needs Analysis document would normally contain more detailed information in relation to the health and mobility of the patients currently on the registered practice list (i.e. number of patients on specific disease registers and number of house bound patients), that level of information is not available from the clinical system at the Askam Practice. However, information from the Quality Outcomes Framework (QOF) suggests that there are a greater number of patients with Hypertension than both the CCG and national averages.

6.1.5 The number of registered patients aged over 70 is higher than the CCG average.

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6.1.6 According to the 2011 Census, the number of registered patients who described themselves as having ‘very good health’ was in line with the national average and above the Cumbrian average.

6.1.7 Feedback from patients highlighted the fact that there was no community pharmacy provision in the village and should the surgery close, patients were worried about access to medicines. The restrictions in relation to public transport meant that travelling to a near-by community pharmacy may be difficult for patients with limited mobility and/or no car.

7. OPTIONS APPRAISAL

Option 1: Dispersal of the Patient List

7.1 The benefits of dispersing the list are:

7.1.1 Continued access to general medical services for patients as they would be able to register with alternative GP practices.

7.1.2 Patients would not have a further period of uncertainty whilst a procurement exercise was undertaken; particularly if this is not successful.

7.1.3 All practices within Morecambe Bay have open practice lists.

7.1.4 The local Primary Care Network has offered support.

7.2 If the list was dispersed, the practice at Askam in Furness would close. Table 3 below shows the risks associated with the dispersal of the list.

Table 3 – List Dispersal risks RISK Disruption for patients, practice has a higher than average number of patients aged 70 years or over. [please refer to paragraph 4.5 of the Health Needs Assessment]

Lack of public transport Reputational risk as patient feedback has strongly indicated a preference for continued service within Askam. Potential disruption for patients during caretaking arrangements (3 months) Impact on neighbouring practices Financial impact to the local system

Option 2: Undertake a Procurement Exercise

7.3 The benefits of a procurement exercise are:

7.3.1 Continuity of a local GP practice within Askam.

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7.4 The risks with a procurement exercise are shown in Table 4 below.

Table 4 – Procurement Exercise Risks RISK Unsuccessful procurement

Financial viability for future provider based upon reducing list size [please see section 4.6 of the Health Needs Analysis]

Financial impact to the local system Identification and preparation of premises and associated costs

Potential disruption for patients during extended caretaking period (6-8 months)

The CCG will work with all system partners to mitigate, wherever possible, the risks relating to the chosen option determined by the Primary Care Commissioning Committee.

8. SUMMARY

8.1 Dr Jain is the sole holder of a GMS contract providing medical services to 1,539 patients as at 01 January 2020 (reduced to 1490 as at 11th February 2020).

8.2 The GMS contract held by Dr Jain will end on 31 March 2020.

8.3 A series of patient engagement events has been held at Askam Practice together with a survey for patients to complete. The main themes from this have highlighted: the lack of public transport from Askam to neighbouring towns; the lack of access to community pharmacy services within the village of Askam, and the preference of registered patients for a service to continue in the locality.

8.4 Engagement with the market will demonstrate the interest in the potential contract procurement (RFI closes on 13th February and a summary report will be made available to the Primary Care Commissioning Committee members for consideration prior to the Committee on 18th February). Whilst interest shown at RFI stage may be encouraging, it does not guarantee a procurement exercise would be successful given the restrictions in relation to premises, reducing patient list size and local clinical workforce challenges.

8.5 Engagement with local practices has provided mixed results with the most local Practices within the Mid Furness Primary Care Network showing a clear preference for List dispersal but the overall responses from all local practices shows a 60:40 split in favour of Procurement.

February 2020

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Morecambe Bay Clinical Commissioning Group

Health Needs Analysis

Askam in Furness

February 2020

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1 Background

1.1 Dr Jain is the sole holder of a GMS contract for the provision of primary care medical services to patients registered in Askam in Furness and the surrounding areas.

1.2 Dr Jain notified Morecambe Bay Clinical Commissioning Group on 31 December 2019 of his intention to retire from general practise with effect from 31 March 2020.

1.3 As delegated commissioners of primary medical care, Morecambe Bay Clinical Commissioning Group (CCG) must determine the way in which services will be provided to patients registered at the practice from 01 April 2020 onwards. This document sets out information in relation to the current provision of primary medical services in the area together with options for the provision of these in the future.

1.4 NHS England is responsible for the commissioning of the dispensing element of the contract and, therefore, the future provision of this service will be determined by NHS England.

2 General Medical Services Regulations

2.1 In accordance with paragraph 26.6 a Contractor (ie a sole General Practitioner or a partnership made up of General Practitioners) has the right to terminate the General Medical Services (GMS) Contract at any time. The timescales for a sole Contractor are set out in paragraph 26.6.3 of the GMS Contract:

“Where the Contractor gives notice to the Board under clause 26.6.1, the Contract terminates three months after the date on which the notice was given (“the termination date”), unless the termination date does not fall on the last calendar day of a month, in which case the Contract terminates instead on the last calendar day of the month in which the termination date falls.” [source: GMS contract, NHS England]

2.2 Dr Jain has complied with the requirement to provide three months’ notice of his intention to retire from general practice.

3 Askam in Furness

About the local area

3.1 Askam in Furness is located on the southern shore of the Duddon Estuary and is part of Furness peninsula. It is a nineteenth century village which grew around the excavation of iron ore in the area. Askam together with the adjoining village of Ireleth, which dates back to the Viking occupation of Britain, covers a large area which includes: Roanhead, Green Haume, Greenscoe, Paradise, Dunnerholme and Marsh Grange. Ireleth is the smaller of the two villages although Askam and Ireleth are now considered to be joined.

3.2 The parish of Askam and Ireleth is part of Barrow Borough Council and sits within the electoral division of Dalton in Furness North which has a population of 6,089

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residents [source: Cumbria County Council, Cumbria Intelligence Observatory 2017]5.

Population Information

3.3 The ‘Settlement Profiles for Barrow Borough’ produced by Barrow Borough Council in October 2017, gives the population of Askam and Ireleth as 3,280 residents6. The number of registered patients at Askam in Furness surgery as at 01 January 2020 was 1,539 patients.

3.4 In terms of the population of Cumbria, information from the Cumbria Joint Strategic Needs Assessment 2015 – 2017 states:

“The resident population of Cumbria was estimated to be 498,100 persons at mid-2013 from Office of National Statistics (ONS); an increase of +6,700 persons (+1.4%) since mid-2003 (England & Wales +7.7%). All but one of Cumbria’s districts followed the county- wide trend in experiencing an overall increase in population between mid-2003 and mid-2013; the exception being Barrow-in-Furness, where the population decreased by 4.3%, the second biggest decrease out of all local authority districts in England & Wales. The greatest proportional increase amongst Cumbria’s districts was seen in Carlisle (+5%). The GP registered population tends to be slightly higher than the ONS figures and as of October 2014 513,922 patients were registered at GP practices in Cumbria.” [source: Cumbria Joint Strategic Needs Assessment 2015-2017, Introduction]

3.5 The Needs Assessment also found that 84 of Cumbria’s communities rank amongst the 10% most deprived in England in relation to geographical barriers to services with average travel times to key services being longer than the national average7. Cumbria Intelligence Observatory shows that for the electoral ward of Dalton in Furness North 11% of households experience fuel poverty8 whilst 8% of children live in low income families; the Cumbrian average is 12% for both categories.

3.6 The Public Health Profile for Barrow in Furness9, published by Public Health England [data as at November 2019], shows that:

 The health of people in Barrow-in-Furness is varied compared with the England average;  Barrow-in-Furness is one of the 20% most deprived districts / unitary authorities in England;  Approximately 16.6% (1,975) of children live in low income families;  Life expectancy for both men and women is lower than the England average;

5 Reference: https://www.cumbriaobservatory.org.uk/parish-profiles/ 6 Reference: EL4 005 Settlement Profiles for Barrow Borough 2017 7 Reference: https://www.cumbria.gov.uk/eLibrary/Content/Internet/536/671/4674/6164/6995/42138143423.pdf 8 Reference: https://www.cumbriaobservatory.org.uk/deprivation/report/view/df4a8f4994224d6586f40fff139821bb/E05003147 9 Reference: https://fingertips.phe.org.uk/profile/health-profiles/area-search- results/E12000002?search_type=list-child-areas&place_name=North ______

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 Life expectancy is 11.5 years lower for men and 10.5 years lower for women in the most deprived areas of Barrow-in-Furness than in the least deprived areas;  In Year 6, 22% (152) of children are classified as obese.  The rate of alcohol-specific hospital stays among those under 18 is 127 [rate per 100,000 population], worse than the average for England. This represents 17 admissions per year;  Levels of teenage pregnancy, GCSE attainment and breastfeeding initiation are worse than the England average.  The rate of alcohol-related harm hospital stays is 776 [rate per 100,000 population], worse than the average for England; this represents 516 admissions per year;  The rate of self-harm hospital stays is 411 [rate per 100,000 population], worse than the average for England; this represents 264 stays per year.  Estimated levels of adult excess weight are worse than the England average;  Rates of sexually transmitted infections and TB are better than average.  The rates of under 75 mortality rate from cardiovascular diseases and under 75 mortality rate from cancer are worse than the England average [source: Public Health England, Health Profile data]

3.7 Cumbria Intelligence Observatory shows10, for ‘self-reported health’ the number of residents who considered they had ‘very good health’ is 47.2% which is in line with the national average and slightly above the Cumbrian average; see Table 1 below.

Table 1 – Self Reported Health 2011 Census Dalton North Cumbria England

Count % Count % Count %

Very bad health 80 1.2 6,481 1.3 660,749 1.2

Bad health 300 4.7 23,604 4.7 2,250,446 4.2

Fair health 857 13.14 71,966 14.4 6,954,092 13.1

Good health 2,147 33.5 172,789 34.6 18,141,457 34.2

Very good health 3,023 47.2 225,018 45 25,005,712 47.2 [source: Office for National Statistics]

3.8 Data from Cumbria Intelligence Observatory11shows that Dalton North has a higher percentage of residents aged 65 and over than the England average although this is lower than the Cumbrian average; see Table 2 below. In respect of the patients registered at Askam in Furness 535 (34%) are aged 60 years and over12.

10 Reference: https://www.cumbriaobservatory.org.uk/health-social- care/report/view/1fe7afe0680f4f27a14b74ffdeca920d/E05003147 11 Reference: www.cumbriaobservatory.org.uk/population/report/view [select Dalton North] 12 Please refer to Section 4.5 for information on practice level data ______

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Table 2 – Population Estimates of People by Broad Age Group (2018) Dalton North Cumbria England

Count % Count % Count %

Persons aged 0 - 15 971 16.1 82,206 16.5 10,748,458 19.2

Persons aged 16 – 64 3,790 62.8 296,508 59.4 34,049,467 62.6

Persons aged 65+ 1,277 21.2 120,174 24.1 10,179,253 18.2 [source: Office for National Statistics]

3.9 In respect of disease prevalence, data from the Quality and Outcomes Framework (QOF) (see Table 3 below13) shows there is a higher prevalence of patients with hypertension than both the Cumbrian and national averages. These figures are derived from the practice’s clinical system and are based on the number of patients placed on the appropriate register by GPs expressed as a percentage of the total practice population. The prevalence of asthma, chronic kidney disease, and depression are all below the Cumbrian and national averages.

Table 3 – Disease Prevalence (QOF) 2018/19 [A cell coloured red indicates prevalence at a significant variance to the CCG average, ie either significantly below or above the CCG average.] Disease area Clinical CCG Average National Prevalence (% of Average practice population)

Asthma 4.23 6.95 6.05

Atrial fibrillation 2.43 2.45 1.98

Cancer 3.55 3.55 2.98

Chronic kidney disease 1.76 4.05 4.09

Chronic obstructive pulmonary 2.05 2.27 2.17 disease

Dementia 0.81 1.06 0.78

Depression 9.95 12.6 10.74

Diabetes mellitus 5.93 6.76 6.93

Epilepsy 1.17 0.92 0.79

Heart failure 1.00 1.09 1.07

Hypertension 17.17 14.97 13.96

Learning disability 0.37 0.49 0.50

Mental health 0.81 0.94 0.96

Osteoporosis: secondary 0.25 0.37 0.79 prevention of fragility fractures

13 Reference: https://qof.digital.nhs.uk/search/index.asp ______

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Disease area Clinical CCG Average National Prevalence (% of Average practice population)

Palliative care 0.37 0.77 0.40

Peripheral arterial disease 0.50 0.87 0.60

Rheumatoid arthritis 1.07 0.93 0.76

Secondary prevention of 4.11 3.85 3.1 coronary heart disease

Stroke and ischaemic attack 2.24 2.30 1.77 [source: NHS Digital]

Local Developments and Housing

3.10 The ‘Settlement Profiles for Barrow Borough’ (October 2017) gives the approximate number of houses in Askam and Ireleth as 1,457. This figure is likely to have changed from 2017 to 2020 due to the housing developments in the area.

3.11 The Barrow Borough Council’s Local Plan 2016 – 2031, states that:

“Askam & Ireleth “These villages currently fall within the same development cordon. They are located on a bus14 and train route which links them to the larger settlements of Barrow and Dalton and benefit from primary schools, community centre and hall, petrol filling station, shops, public houses, employment and a doctor’s surgery.“ [source: paragraph 7.4.5, Barrow Borough Local Plan]

and goes on to state:

“Policy H4: Development Cordons “In the following villages, residential development and the conversion of existing buildings for residential purposes will be permitted within the development cordon, especially if it contributes to the maintenance of that community:

“Askam & Ireleth, Lindal, Newton, North Scale, Rampside.” [source: paragraph 7.4.10, Barrow Borough Local Plan]

3.12 The Planning Department at Barrow Borough Council has confirmed that as at January 2020, three applications for housing developments are being taken through the relevant consultation processes. These are: Land at Lots Road, creation of 22 dwelling; housing development site at Lots Road, creation of 29 dwellings and Duddon Road, Askam, creation of up to 46 houses, giving a total of up to 97 additional dwellings. An approximate indication of the additional number of residents as a result of these developments would be 23315. The Local Plan 2016 – 2031

14 Please note: a regular bus service is no longer available – see section on Transport 15 Calculated using Office for National Statistics: “In the UK there were 27.2 million households in 2017, resulting in an average household size of 2.4.” ______

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identifies other options for development up to a total of an additional 95 dwellings (approximate additional number of residents being 22816).

Travel / Public Transport

3.13 Askam in Furness is approximately 7 miles distance from Barrow in Furness17 and approximately 3 miles from Dalton in Furness. Travel by car from the main arterial route, M6, to Askam is approximately 30 miles. Table 4 below shows the percentages of car ownership for Dalton North; this is broadly in line with the Cumbrian and England averages.

Table 4 – Number of Cars / Vans per Households Dalton North Cumbria England

Count % Count % Count %

1 car or van 1,175 43.8 99,389 44.8 9,301.776 42.2

2 cars or vans 804 30.0 57,798 26.0 5,441,593 24.7

3 cars or vans 159 5.9 12,825 5.8 1,203,865 5.5

4 or more cars 67 2.5 4,452 2.0 424,883 1.9 [source: Office for National Statistics]

3.14 Public transport in Askam in Furness is extremely limited. There is a bus service which operates on Wednesdays only from Kirkby in Furness to Barrow in Furness (passing through Askam) with two buses (11 am and 2 pm); however, this bus does not stop in Dalton in Furness. The cost of a journey, one-way, is £7.5018. The previous bus route from Barrow in Furness to Millom, which again passed through Askam, ceased in July 2018 and, therefore, there are now no direct buses between Askam in Furness and Dalton in Furness.

3.15 Askam in Furness is on the Cumbrian coastline train route (Barrow in Furness to Workington). There are hourly trains between Askam in Furness and Barrow in Furness; the journey takes approximately 15 minutes with a single fare (ie one way) costing approximately £2.60. Trains to Dalton in Furness require a change at Barrow in Furness; the journey takes 30 minutes and a single fare costs approximately £5.50 (an off-peak return fare costs approximately £5.70).

3.16 The distance from the present surgery site to the railway station for pedestrians is approximately 0.6 miles and walking at an average pace of 3.5 miles per hour would take around 11 minutes to complete the journey. The route is mainly level, although there is a slight incline on one of the roads.

3.17 For pedestrians, the distance between the railway station at Dalton in Furness to the practice located at Market Street is approximately a quarter of a mile; it should be noted that the walk from the surgery to the railway station involves walking uphill. In Barrow in Furness, the nearest practice to the railway station is Norwood Medical Practice at a distance of approximately 0.33 miles; the route between the two is flat once pedestrians have left the station.

16 The Local Plan says 146, but this includes 51 houses on the Urofoam site which have been included in the list of planning applications 17 Distance Askam to Barrow in Furness town centre 18 Details provided by local Councillor ______

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Employment

3.18 Following the closure of the K Shoe factory in 1997, Askam in Furness lost its main employer. The main areas of employment for residents in Askam in Furness are: BAE Systems in Barrow in Furness; the Sellafield Nuclear Processing Plant in North Cumbria (although this is some distance from Askam, approximately 32 miles), and Glaxo SmithKline Ltd in Ulverston (however, manufacturing at this plant is planned to cease with the loss of a significant number of jobs)19.

3.19 Table 5 below shows data from the Office for National Statistics regarding the percentage of people in employment in the Dalton in Furness North electoral ward. Dalton in Furness North has a higher percentage of people in employment than both the Cumbrian and England averages. However, the percentage of retired people is higher than the England average but slightly below the Cumbrian average.

Table 5 - Economic Activity By Type 2011 Dalton North Cumbria England

Count % Count % Count %

F/T employee 1,936 40.9 136,835 37.1 15,016,564 38.6

P/T employee 776 16.4 59,570 16.1 5,333,268 13.7

Full time student 124 2.6 9,170 2.5 1,336,823 3.4

Part time 399 8.4 39,234 10.6 3,793,632 9.8 student

Unemployed 142 3 12,346 3.3 1,702,847 4.4

Retired 847 17.9 66,857 18.1 5,320,691 13.7 [source: Office for National Statistics]

Education

3.20 There are two primary schools in in the area: Askam Village Primary School and St Peters Church of England School in Ireleth. The nearest secondary school is Dowdales School at Dalton in Furness.

Other Local Amenities / Facilities

3.21 Within the village of Askam there are:

 Co-op Food Store  Post Office and general store  Food outlets [various take-away food outlets]  Village Halls [Temperance Hall – Ireleth; Community Centre – Askam; Band Hall – Askam and dance hall at Rankin Hall]  Sports and Social Club  Petrol Station [located in Ireleth]  Two public houses [one in Askam and one in Ireleth]

19 Reference: article; ‘The Mail’, 13 March 2019 ______

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 Rest Home for the elderly  Rugby League Club  Base for Inshore Rescue service  Golf Club  Football Club

4 Current Primary Medical Services Provision

4.1 Dr Jain is the only GP in Askam in Furness and consequently there are no other GP practices in the village of Askam or in Ireleth. The current practice premises are located at 2 Parklands Drive, Askam in Furness. The premises are owned by Dr Jain. The closest practice is located at Dalton in Furness (approximate distance 2.8 miles by car). The nearest practice in Barrow in Furness is approximately 6 miles distance, a journey of approximately 12 minutes by car. The practice located at Kirkby in Furness is approximately 5 miles from Askam and takes approximately 10 minutes by car.

4.2 There is no community pharmacy provision in Askam in Furness and consequently Dr Jain has authority, from NHS England, to dispense medicines from the practice to patients who meet the eligibility criteria. Essentially an eligible patient is one that lives in a ‘controlled locality’ and at a distance of more than 1.6 km (approximately 1 mile) from a community pharmacy. A controlled locality is an area which has been reviewed under the provisions of the NHS (Pharmaceutical Services) Regulations and has been deemed as being rural in character. Although the dispensing contract is awarded by virtue of the rural nature of an area, there are certain other requirements for GPs providing dispensing services and, consequently, the authority to dispense medicines is held by Dr Jain and will cease on termination of the GMS contract. Currently, approximately 78% of the patients registered with the practice are classed as dispensing patients. The closest community pharmacy to Askam is in Dalton in Furness.

4.3 There are no other NHS services based in locations in Askam in Furness, such as an NHS dentist, Optometrist or other community health services. The closest dental surgery and optometrist are in Dalton in Furness.

4.4 The closest Accident and Emergency Department is located at Furness General Hospital which is approximately 5 miles distance from Askam. The number of A&E attendances per 1,000 patients, (as at November 2019) were 272 which is below the CCG average of 290. The number of emergency admissions per 1,000 patients was 98, again this is below the CCG average of 108 (as at November 2019).

4.5 NHS Digital data for the patients registered at the surgery at Askam in Furness for December 2019 showed that 45% of the patients were Female whilst the remaining 55% were Male (see Table 6 below), with 20% of registered patients being aged 70 years old and over which is higher than the CCG average of 16.31% [source: NHS Digital].

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Table 6 – Split of Male / Female patients as at December 2019 Female Male Total Age Range Number % Number %

0 – 9 years 54 3% 51 3% 7%

10 – 19 years 76 5% 74 5% 10%

20 – 29 years 52 3% 104 7% 10%

30 – 38 years 68 4% 93 6% 10%

40 – 49 years 70 5% 111 7% 12%

50 – 59 years 105 7% 152 10% 17%

60 – 69 years 99 6% 124 8% 14%

70 – 79 years 102 7% 99 6% 13%

80 – 89 years 54 3% 42 3% 6%

90 + years 9 1% 6 0% 1%

TOTAL 689 45% 856 55% 100% [source: NHS Digital]

4.6 Graph 1 below shows the changes in the number of registered patients from March 2018 to January 2020.

Graph 1 - Number of Registered Patients 2018 – 2020 1640

1620

1600

1580

1560

1540

1520

1500

1480 Mar-18 Jun-18 Sep-18 Dec-18 Mar-19 Jun-19 Sep-19 Dec-19

[source: NHAIS system]

4.7 Information supplied by the District Nursing Team late 2019 suggests that there were 13 patients classed as ‘housebound’ and likely to require home visits by the GP; updated information will be presented to the Committee if available.

4.8 The GMS Contract is split into three main areas in respect of services provided to patients, these are: Essential Services, Additional Services and Enhanced Services. All practices holding a GMS contract provide Essential Services to patients. The

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majority of practices also provide Additional Services and all have the choice of providing Enhanced Services.

4.9 The Askam Practice currently provides Essential services as required by the Contract and also provides the following services

Additional Services

Childhood Immunisations and Vaccinations Immunisations and Vaccinations Cervical Screening Maternity Medical Services Contraceptive Services Minor Surgery Child Health Surveillance

Directed Enhanced Services

HPV completing dose (booster) Meningococcal ACWY freshers Meningococcal B PCV Hib/ Men C MMR (aged 16 and over) Pertussis (Pregnant Women) Pneumococcal Polysaccharide (PPV) Rotavirus Shingles (Catch up) Shingles (Routine) Childhood Seasonal Influenza Seasonal Influenza Learning Disabilities Health Check Scheme Extended Hours Access (now as part of the Primary Care Network DES) Minor Surgery Out of area registration

Local Enhanced Services [NB: all practices have the option of providing these]

Morecambe Bay CCG Quality Improvement Scheme (QIS) Anti-coagulation monitoring Minor Injuries Shared Care Post-Operative Dressings Prostate Cancer / Zoladex

4.10 The practice currently opens from 08:00 to 18:30 Monday, Tuesday, Thursday and Friday; on Wednesday the surgery closes at 12 noon. The practice does not open on Public and Bank Holidays as this is not required by the GMS contract. Cumbria Health On-Call (CHOC) provides services out of hours for patients in Askam in Furness. As Dr Jain lives in the village and in close proximity to the practice premises, in the event of a patient needing to be seen urgently on a Wednesday afternoon, Dr Jain would have made arrangements to see / treat the patient personally despite the practice being closed. The current opening hours, however, are not in accordance with the core hours set out in the contract (ie 08:00 to 18:30 Monday to Friday).

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4.11 Dr Jain does not operate an appointment system and has an ‘open access’ arrangement whereby patients wanting to see the GP present at the practice and wait to see the GP. Table 7 below shows the results from the National GP Patient Survey in relation to the questions regarding access to services. As can be seen from the table, the majority of patients completing the survey confirmed they were satisfied with the open access arrangement.

Table 7 – GP Patient Survey National Morecambe The Surgery, Average Bay CCG Askam in (%) Average Furness (%) (%)

Easy to contact practice by ‘phone 68 74 100

Patients who were satisfied with general practice appointment times 65 72 89 available

Were offered a choice of appointment when they last tried to 62 65 86 make a general practice appointment

Patients who were satisfied with the 74 77 97 type of appointment offered [source: National GP Patient Survey]

4.12 In addition to Dr Jain, the practice has a Practice Nurse who works at the practice on two days per week. Consequently, patients do have access to a female clinician although this is limited. Dr Jain also employs 2 dispensers who manage the dispensary service; both of these employees also act as receptionists.

Current Practice Area / Boundary

4.13 A review of the registered patient postcode data undertaken by NHS England shows that the majority patients live in the following areas, although there are some patients registered from Millom and Grange over Sands:

 Askam in Furness  Ireleth  Dalton in Furness  Barrow in Furness  Walney Island (Barrow in Furness)  Kirkby in Furness  Ulverston

4.14 The practice boundary for Askam in Furness is shown at Appendix 1. The practice boundary incorporates the areas of Askam in Furness and Ireleth. Dr Jain has also set an outer boundary which crosses the main road (A590) and incorporates areas in Dalton in Furness. In terms of registering patients, the practice is obliged to register patients who live within the boundary unless the CCG has given permission for the list of patients to be closed. There is no obligation for the practice to register new patients who live in the outer boundary although the practice can choose to do so. If

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it chooses to register patients living in the outer boundary, then the full range of services should be provided to those patients including home visits.

4.15 As has been said above, Dr Jain has signed-up to provide ‘Out of Area’ services. This is a specific service which aims to provide access to GPs for patients who live in the practice area but who may be registered with a GP away from home. The service means Dr Jain would be asked to undertake a home visit for a patient living within the Askam in Furness practice boundary area but registered with a practice away from their home, should this be needed. The registered GP practice would determine whether a home visit was clinically necessary. This service is managed by NHS England.

5 Neighbouring Practices

5.1 Table 8 below shows the proximity of practices in the surrounding areas to Askam in Furness.

Table 8 – Neighbouring Practices List size (as Distance to Approximate Practice at 01 January Askam (in travelling time 2020) miles by car) (by car) The Surgery, 1,539 Askam in Furness Market Street Surgery 8,693 2.8 7 minutes (Dalton in Furness) Duddon Valley Medical Practice 3,312 5.0 10 minutes (Kirkby in Furness) Bridgegate Medical Centre 8,934 6.4 13 minutes (Barrow in Furness) Liverpool House Surgery 5,312 6.6 13 minutes (Barrow in Furness) The Family Practice 3,173 6.8 13 minutes (Barrow in Furness) Risedale Surgery* 6,517 7.1 14 minutes (Barrow in Furness) Abbey Road Surgery* 6,611 7.1 14 minutes (Barrow in Furness) Atkinson Health Centre* 4,469 7.1 14 minutes (Barrow in Furness) Dr Johnston & Partners 4,476 7.0 14 minutes (Ulverston) Dr Murray & Partners 11,139 7.0 14 minutes (Ulverston) Burnett Edgar Medical Centre 4,362 7.5 15 minutes (Barrow In Furness) * NB: These three practices have relocated to Alfred Barrow Health Centre

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5.2 Table 9 below shows the distance in miles for patients who may walk to surgeries in Barrow in Furness from the railway station (in Barrow).

Table 9 – Walking distances for Pedestrians (from nearest railway station to neighbouring practices) Practice Distance in Miles Approximate from Dalton Railway Walking times Station

Market Street Surgery (Dalton in Furness) 0.25 4 minutes

Practice Distance in Miles Approximate from Kirkby Railway Walking times Station

Duddon Valley Medical Practice (Askew 0.14 3 minutes Gate, Kirkby in Furness)

Practice Distance in Miles Approximate from Barrow Walking times Railway Station

The Family Practice (Barrow in Furness) 0.28 5 minutes

Norwood Medical Practice (Barrow in 0.33 6 minutes Furness)

Duke Street Surgery (Barrow in Furness) 0.65 13 minutes

Abbey Road Surgery* (Barrow in Furness) 0.72 14 minutes

Atkinson Health Centre* (Barrow in 0.72 14 minutes Furness)

Risedale Surgery (Barrow in Furness)* 0.72 14 minutes

Bridgegate Medical Centre (Barrow in 1.09 21 minutes Furness)

Liverpool House Surgery (Barrow in 1.14 22 minutes Furness)

Burnett Edgar Medical Centre (Barrow In 1.82 36 minutes Furness)

Practice Distance in Miles Approximate from Ulverston Walking times Railway Station

Dr Johnston & Partners (Ulverston) 0.65 13 minutes

Dr Murray & Partners (Ulverston) 0.65 13 minutes * NB: These three practices have relocated to Alfred Barrow Health Centre

5.3 Additional information from the GP Patient Survey for the surgery at Askam in Furness together with the same results for neighbouring practices is shown in Table 10 below.

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Table 10 – GP Patient Survey Results Easy to contact Patients who Were offered a Patients practice by were satisfied choice of who were ‘phone with general appointment satisfied practice when they last with the appointment tried to make a type of times general practice appointment available appointment offered The Surgery, Askam in 100 89 86 97 Furness

Market Street Surgery 66 60 54 75

Duddon Valley Medical 95 83 80 88 Practice Norwood Medical 66 61 51 71 Practice

Abbey Road Surgery 80 76 69 85

Risedale Surgery 59 52 37 65

Atkinson Health Centre 97 78 63 77

Bridgegate Medical 77 67 52 87 Centre Burnett Edgar Medical 97 82 68 83 Centre

Duke Street Surgery 91 83 53 77

The Family Practice 66 48 49 67

Liverpool House Surgery 95 92 77 93

Dr Johnston & Partners 91 79 77 90 (Ulverston) Dr Murray & Partners 97 88 80 94 (Ulverston) Morecambe Bay CCG 74 72 65 77 average

National average 68 65 62 74 [RAG rating: Green = above CCG and national averages; Amber = above national average but lower than CCG average; Red = below CCG and national averages]

5.4 Appendix 2 contains the practice boundaries for the neighbouring practices. Three practices have boundaries which include areas of Askam in Furness; these are Market Street Surgery, Duddon Valley Medical Practice and Risedale Surgery. Risedale Surgery’s practice boundary, however, does not include Ireleth.

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6 Neighbouring Pharmacies

6.1 Table 11 below shows the opening times of, and approximate travel distances to, community pharmacies in Barrow in Furness, Dalton in Furness and Ulverston.

Table 11 – Community Pharmacies Information Approximate Distance Travelling time Practice Opening Times from Askam in minutes (by in Miles car) Lloyds Pharmacy, Dalton in 08:30-18:30 Mon-Fri; 2.7 6 Furness, LA15 8DL 09:00-17:00 Saturday Cohens Chemist, Ormsgill, 09:00-17:0 Mon-Fri; 4.8 9 Barrow in Furness, LA14 4BX 09:00-12:00 Saturday Cohens Chemist (Settle St), 09:00-17:00 Mon-Fri 5.8 12 Barrow in Furness, LA14 5HQ Cohens Chemist (Ainslie St), 09:00-18:30 Mon-Fri; 5.8 12 Barrow in Furness, LA14 5AY 09:00-12:00 Saturday 08:00-23:00 Mon; 7:00- Asda Pharmacy, Barrow in 23:00 Tues-Fri; 07:00- 5.8 10 Furness, LA14 5UG 22:00 Sat; 11:00-17:00 Sun Cohens Chemists (Friars Lane), 08:30-18:00 Mon-Fri; 6.3 12 Barrow in Furness, LA13 9NN 09:00-13:00 Saturday Cowards Pharmacy, Barrow in 09:00-18:00 Mon-Fri; 6.4 13 Furness, LA14 5SR 09:00-12.30 Saturday Boots, Ulverston, LA12 7LR 09:00-17:30 Mon-Sat 6.6 13 Boots (Risedale Road), Barrow 08:45-18:30 Mon-Fri; 6.6 13 in Furness, LA13 9RD 09:00-17:30 Saturday Cohens Chemist (Rawlinson 09:00-18:30 Mon-Fri; St), Barrow in Furness, LA14 6.6 15 09:00-12:00 Saturday 2DN 08:00-22:30 Mon; 06:30- Tesco Instore Pharmacy, 22:30 Tue-Fri; 06:30- 6.6 13 Barrow in Furness, LA14 2NE 22:00 Sat; 11:00-17:00 Sun Cohens Chemist, Ulverston, 09:00-17:00 Mon-Fri 6.8 13 LA12 7DX Cohens Chemist (68 Dalton 09:00-17:30 Mon-Fri; Road), Barrow in Furness, LA14 7.0 14 09:00-12:30 Sat 1JB Cohens Chemist, (36 Dalton Road), Barrow in Furness, LA14 09:00-18:00 Mon-Fri 7.0 14 1HY Boots (Alfred Barrow Health 08:45-18:00 Mon-Fri; Centre), Barrow in Furness, 7.0 14 08:45-17:00 Saturday LA14 2LB Boots (Portland Walk), Barrow 09:00-17:30 Mon-Sat; 7.2 15 in Furness, LA14 1DB 11.00-16:00 Sunday

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Approximate Distance Travelling time Practice Opening Times from Askam in minutes (by in Miles car) Cohens Chemist, Walney 09:00-18:00 Mon-Fri; Island, Barrow in Furness, LA14 7.6 15 09:00-13:00 Saturday 3HY Cohens Chemist, (Anchor 09:00-17:30 Mon-Fri; Road), Barrow in Furness, LA14 7.6 15 09:00-12:00 Saturday 3QW

7 Engagement

Patients

7.1 On 13th January 2020, Morecambe Bay CCG wrote to patients informing of Dr Jain’s retirement from general practise; a patient survey was enclosed with this letter. As the letter was addressed to ‘Head of Household’ and one copy of the survey sent, additional copies were available from the surgery and could also be completed on- line. The questions posed in the survey were:

i. What is the most important to you when accessing GP services (please indicate most important):

- Location / distance from home - Access to male and female GPs and clinicians - Access to medication dispensing (located within the GP practice) - Additional services on offer, ie extended access to GPs, minor surgery, health checks etc

ii. Are there any other services or considerations that we haven’t mentioned above that are important to you when accessing GP services?

iii. Please tell us here which other services or considerations are important to you.

iv. If you had to travel to attend GP services, how would you do this?

- Use my car - A lift from a friend / relative - Taxi - Public transport (bus, train) - Other, please specify

v. During short period when the dispensary was closed how did you access your medications?

- I waited until the surgery re-opened - I went to a pharmacy outside the village - I used a delivery service - I didn’t need any medication during those times - Other, please specify

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vi. What would the impact be to you and your family if a GP surgery was not located within Askam?

vii. If a replacement GP practice provider is secured for the practice in Askam we would initially seek to keep the service at the current location (this is subject to agreement between Dr Jain and the new provider). However, if this is not possible, do you have a suggestion for an alternative location? If so, please tell us where:

viii. If a new provider is secured, what types of access are preferable to you (please tick all that apply)?

- Drop-in sessions (no appointment needed) - Pre-booked clinics (appointments needed) - Telephone consultations - Video consultations - Extended evening access - Early morning access - Other, please specify

ix. Please tell us here if you have any further comments that you would like to share in relation to the future of the GP practice in Askam.

7.2 In addition to the patient survey, a number of Patient Engagement events were held at the surgery in Askam in Furness as follows:

 Wednesday 22 January: 6.30 pm to 8.00 pm  Thursday 23 January: 11.00 am to 12.30 pm  Tuesday 28 January: 2.00 pm to 3.30 pm  Wednesday 29 January: 6.30 pm to 8.00 pm

7.3 Patients had until 03 February 2020 to complete the survey; feedback from surveys received by the CCG is shown in Table 12 below. A total of 446 completed surveys were received (approximately 29% of the patient list size); the main feedback from patients both through the patient survey and the face-to-face engagement events were:

 Lack of public transport: Patients were concerned that the lack of public transport meant that it would be extremely difficult for elderly and / or disabled patients to travel via public transport to surrounding practices. Whilst the nearest surgery was at Dalton, patients were concerned that there was no direct train or bus service to Dalton. The cost of taxi journeys was a concern to a number of patients, specifically those on a limited income.

 Lack of pharmacy provision in Askam: Patients were concerned that without the GP practice there was no access to medicines without travelling to Dalton, Barrow or Ulverston.

 Lack of available places at local surgeries: Some patients reported that they had tried to register at alternative practices without success as they had been told that the lists were full. At the engagement events, patients were assured that the CCG would work with local practices to ensure that sufficient places were available at local practices should the decision be taken to disperse the list.

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 Preference for Drop-in Session: Patients reported the present system of ‘open access’ (ie no set appointments) worked well and would be preferable for the future.

Table 12 – Feedback from Patient Survey QUESTION RESPONSE OPTIONS RESPONSE RATE

Location / Distance from 70.8% Home

What is most important to you when Access to medication 64.2% accessing GP Services (please rate in dispensing (located within order of importance, with the most the GP practice) important at the top)? [NB: respondents completing a paper Additional services on offer 50.3% copy were asked to number the options (ie minor surgery, health in the order of importance from 1 to 4 checks) with 1 being the most important]* Access to male / female 52.3% GPs, clinicians (ie nurses, health care assistants)

Are there any other services or Yes 37% considerations that we haven't mentioned above that are important to No 63% you when accessing GP services?

126 respondents Latest Responses: Please tell us more here Nurse Dispensary

Use my car 44%

A lift from a friend/relative 11%

If you had to travel to attend GP Taxi 7% services, how would you do this? Public transport (bus, train 11% etc)

Other 27%

I waited until the surgery re- 34% opened

I went to a pharmacy outside 29% During short periods when the the village dispensary was closed how did you access your medications? I used a delivery service 3%

I didn’t need any medications 24%

Other 10%

418 responses Latest Responses: What would be the impact to you and “we are both 75+ years your family if a GP surgery was not old and suffer from located within Askam? several medical problems which ______

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QUESTION RESPONSE OPTIONS RESPONSE RATE require constant treatment. We are both struggling with mobility issues. Therefore it would be very hard.” “Have to travel to Dalton or Barrow”.

298 responses Latest responses: If a replacement GP practice provider is secured for the practice in Askam we “The local community would initially seek to keep the service hall or other accessible at the current location (this is subject to place”. agreement between Dr Jain and the “Do not know” new provider). However, if this is not possible, do you have a suggestion for “Not sure” an alternative location? If so, please tell “Land opposite Co-op” us where “units at station”

Drop in sessions (no 42 appointment needed)

Pre-booked clinics 141 (appointments needed)

If a new provider is secured what types Telephone consultations 105 of access are preferable to you (please select all that apply)? Video consultations 13

Extended evening access 150

Early morning access 134

Other, please specify: 49

Do you have any further comments you Yes 270 would like to share in relation to the future of the GP practice in Askam? No 156 * This is an exact count of the scoring provided by respondents. However, respondents completing a paper copy of the survey did not use the correct scoring system and, based on the comments made, it is thought others had inadvertently reversed the scores.

Neighbouring Practices

7.4 A survey was also sent to neighbouring practices which asked practices the following questions:

i. Does your practice have a strong preference in terms of the future of the surgery at Askam in Furness; specifically:

- List dispersal (meaning the practice will close) - CCG to find a new provider

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ii. If patients were dispersed what impact would you anticipate for your surgery and would this be manageable?

- Yes - No

iii. If the list was dispersed and short-term support was required in terms of managing the close down of the clinical system (and associated tasks), would your surgery be able to help for a period of up to 6 months:

- If yes - please identify proposed costs - No

iv. If a managed dispersal was considered, would your surgery wish to be the chosen dedicated provider?

- Yes - No

v. If procurement was undertaken would your practice (either independently or as part of a joint application) wish to compete for the Askam in Furness contract?

vi. If procurement was undertaken the CCG would need full Caretaking arrangements for a period of approximately 6 months; would your practice (either independently or as part of a joint application) be in a position to provide cover:

- Yes – please identify proposed costs - No

7.5 Responses were received from ten of the practices in the Barrow and Millom PCN and the Mid-Furness PCN. Feedback from the neighbouring practice surveys is shown in Table 13 below.

Table 13 – Feedback from Neighbouring Practices Survey QUESTION YES NO

Does your practice have a strong preference in terms of the future of the surgery at Askam in Furness; specifically:

List Dispersal (meaning the practice will close) 4

CCG to find a new provider 6

If patients were dispersed what impact would you anticipate for your 5 5 surgery and would this be manageable? [Yes / No]

If the list was dispersed and short-term support was required in terms of 3 7 managing the close down of the clinical system (and associated tasks), would your surgery be able to help for a period of up to 6 months? [Yes / No]

If a managed dispersal was considered, would your surgery wish to be 2 8 the chosen dedicated provider? [Yes / No]

If procurement was undertaken would your practice (either independently 1 8* or as part of a joint application) wish to compete for the Askam in ______

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QUESTION YES NO Furness contract? [Yes / No]

If procurement was undertaken the CCG would need full Caretaking 2 8 arrangements for a period of approximately 6 months; would your practice (either independently or as part of a joint application) be in a position to provide cover? [Yes / No] * NB: One practice did not answer this question

7.6 Specific comments made were:

Mid-Furness PCN – joint response

“The very clear opinion of the members of the PCN is that the patients should be dispersed among the neighbouring practices in the PCN.

“Please keep us abreast of any developments in Askam and let me know if there is any way that we can assist in this difficult process. Needless to say our main concern at the moment is that there is a seamless transition for the patients of Askam to a new service.”

Other comments from survey

“We are happy to have some/all of the patients, might need financial support 6/12 depending on the size of the disruption.”

“Purchase of the building has been the stumbling block as Dr Jain has refused to lease this. Therefore list dispersal is the only option left available and we are happy to take on his patients to provide them with a local service and dispensary to which they are accustomed.”

“We would like to be able to help but uncertainty regarding premises would be an issue. We would not have time to source new premises as we would want the service to remain in Askam as providing a service from Barrow may prove difficult due to the immobility of patients and lack of good transport.”

“Our Practice manager is providing managerial support to Askam through CCG/LMC and is able to continue this throughout this period however we are unable to offer any clinical support due to current resources/demand.”

“We could probably cover in the short term in terms of GP and nursing but this would depend on what was needed - we would need locum cover to release GPs”

“I haven't answered 8 as we don't have enough information; not really so sure about 9, either. Our preference is dispersal. Procurement is fine, but it could upset the balance of our PCN if it is run by a practice outside Mid Furness PCN.”

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Market Engagement

7.7 As part of understanding the viability of securing an alternative provider, the CCG undertook a market engagement exercise by publishing a ‘Request for Information’ (RFI). This notice was published via the Official Journal of the European Union (OJEU) and Contracts Finder. This process was managed by procurement experts from North East Commissioning Support Unit (NECS). Practices within Morecambe Bay CCG were notified of the publication of the RFI. The feedback from the market engagement exercise will be collated following the end of the RFI period (13 February 2020) and provided to the Primary Care Commissioning Committee prior to its meeting on 18 February 2020.

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APPENDIX 1 – PRACTICE BOUNDARY – ASKAM IN FURNESS

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APPENDIX 2 – NEIGHBOURING PRACTICES’ BOUNDARIES

Market Street, Dalton in Furness

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Duddon Valley Medical Group

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Norwood Medical Practice

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Bridgegate Medical Practice

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Liverpool House Surgery

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The Family Practice Duke Street Surgery

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Dr Johnston & Partners

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Dr Murray

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Risedale Surgery

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Atkinson Health Centre

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Abbey Road Surgery

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Burnett Edgar Medical Centre

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Equality Impact and Risk Assessment Stage 2 for Services Askam in Furness General Medical Services

Equality & Inclusion Team, Corporate Affairs For enquiries, support or further information contact Email: [email protected]

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EQUALITY IMPACT AND RISK ASSESSMENT TOOL FOR SERVICES STAGE 2

ALL SECTIONS – MUST BE COMPLETED Refer to guidance documents for completing all sections SECTION 1 - DETAILS OF PROJECT Organisation: Morecambe Bay CCG Assessment Lead: Kate Hudson

Directorate/Team responsible for the assessment: Primary Care

Responsible Director/CCG Board Member for the assessment: Hilary Fordham Who else will be involved in undertaking the assessment: Primary care team members, commucations and engagement team members, equality and inclusion team members. Date of commencing the assessment: 04/02/2020 Date for completing the assessment: 12/02/2020

EQUALITY IMPACT ASSESSMENT Please tick which group(s) this service / project will or may Yes No Indirectly impact upon? Patients, Service Users  Carers or Family  General Public  Staff  Partner Organisations  Background of the service / project being assessed: Dr. Jain is the sole holder of a GMS contract for the provision of primary care medical services to patients registered at The Surgery in Askam in Furness and the surrounding areas. Dr. Jain notified Morecambe Bay Clinical Commissioning Group (CCG) on 31 December 2019 of his intention to retire from general practice with effect from 31 March 2020. The Surgery operates from one site in Askam in Furness and has a list size of 1,542 patients across 63 Lower Super Output Areas (Source: NHS Digital – January 2020). Dr. Jain is the only GP in Askam in Furness and, consequently, there are no other GP practices in the village of Askam or in Ireleth. The current practice premises are located at 2 Parklands Drive, Askam in Furness. The is no community pharmacy provision in Askam in Furness and, consequently, Dr. Jain has authority from NHS England to dispense medicines from the practice to patients who meet the eligibility criteria. Although the dispensing contract is awarded by virtue of the rural nature of an area, there are certain requirements for GPs providing dispensing services. As such, the authority to dispense medicines is held by Dr. Jain and will cease on the termination of the GMS contract. Currently, approximately 78% of patients registered with the practice are classed as dispensing patients. The closest community pharmacy is in Dalton in Furness.

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The closest alternative practice is local at Dalton in Furness (approx. 3.3 miles by car). The nearest practice in Barrow in Furness is approximately 6 miles away. The practice located at Kirkby in Furness is approximately 5 miles away. Public transport in Askam in Furness is extremely limited. There is a bus service which operates on Wednesdays only from Kirkby in Furness to Barrow in Furness (passing through Askam) with two buses – however, this bus does not stop in Dalton on Furness). The cost pf the bus is £7.50 one way. The previous bus route from Barrow in Furness to Millom, which again passed through Askam, ceased in July 2018. There are no direct buses between Askam in Furness and Dalton in Furness. There are hourly trains between Askam in Furness and Barrow in Furness. The journey takes approximately 15 minutes with a single fare costing approximately £2.60. Trains to Dalton in Furness require a change at Barrow in Furness – the journey takes 30 minutes and a single fare costs approximately £5.50. This distance from the current practice site to the railway station is approximately 0.6 miles and take 11 minutes to walk on foot.

What are the aims and objectives of the service / project being assessed? As delegated commissioners of primary medical care, Morecambe Bay Clinical Commissioning Group (CCG) must determine the way in which services will be provided to patients registered at the practice from 01 April 2020 onwards. The CCG is currently exploring two potential options in relation to this: 1. The closure of the practice and the consequent dispersal of the patient list to practices in the surrounding areas 2. The procurement of new provider to enable the continued delivery of primary care services in Askam in Furness. This Equality Impact and Risk Assessment will explore both options in terms of potential or actual areas of risk or disproportionate impact upon protected characteristics and vulnerable groups.

Services currently provided in relation to the project: The GMS Contract is split into three main areas in respect of services provided to patients. These are: Essential Services, Additional Services and Enhanced Services. All practices holding a GMS contract provide Essential Services to patients. The majority of practices also provide Additional Services and all have the choice of providing Enhanced Services. Dr. Jain currently provides Essential Services as required by the GMS contract and also provides the following services: Additional Services:  Childhood Immunisations and Vaccinations  Immunisations and Vaccinations  Cervical Screening  Maternity Medical Services  Contraceptive Services  Minor Surgery  Child Health Surveillance

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Directed Enhanced Services:  HPV completing dose (booster)  Meningococcal ACWY freshers  Meningococcal B  PCV Hib/ Men C  MMR (aged 16 or over)  Pertussis (Pregnant Women)  Pneumococcal Polysaccharide (PPV)  Rotavirus  Shingles (Catch up)  Shingles (Routine)  Childhood Seasonal Influenza  Seasonal Influenza  Learning Disabilities Health Check Scheme  Extended Hours Access  Minor Surgery  Out of Area Registration Local Enhanced Services:  Morecambe Bay CCG Quality Improvement Scheme (optional)  Anti-coagulation monitoring (optional)  Minor Injuries (optional)  Shared Care (optional)  Post-Operative Dressings (optional)  Prostate Cancer / Zoladex (optional) The Surgery currently opens from 08:00 to 18:30 on Monday, Tuesday, Thursday and Friday. On Wednesday, The Surgery closes at 12:00 noon. The practice does not open on Public and Bank Holidays as this is not required by the GMS contract. Cumbria Health On-Call (CHOC) provides services out of hours for patients in Askam in Furness. The current opening hours are not in accordance with the core hours set out in the GMS contract (i.e. 08:00 to 18:30, Monday to Friday). Dr. Jain does not operate an appointment system and has an ‘open access’ arrangement whereby patients wanting to see the GP present at the practice and wait to see the GP. In addition to Dr. Jain, the practice has a Practice Nurse who works at the practice on two days per week. Consequently, patients do have access to a female clinician, although this is limited. Dr. Jain also employs two dispensers who manage the dispensary service – both of these employees also act as receptionists.

Which equality protected groups (age, disability, sex, sexual orientation, gender reassignment, race, religion and belief, pregnancy and maternity, marriage and civil partnership) and other employees/staff networks do you intend to involve in the equality impact assessment? Please bring forward any issues highlighted in the Stage 1 screening

The CCG has directly progressed with the completion of a Stage 2 EIRA in order to fully explore any areas of risk or disproportionate impact upon protected characteristics or vulnerable groups in relation

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to each of the proposed options in relation to The Surgery.

Extensive engagement exercises have taken place that have involved all patients and staff who are likely to affected by Dr. Jain’s decision to terminate his GMS contract. The results of this engagement will be analysed as part of this EIRA and any emerging trends relating to certain protected characteristics or vulnerable groups will be considered.

How will you involve people from equality/protected groups in the decision making related to the project? In line with national direction on patient engagement and consultation, the CCG has ensured that the engagement process considered protected characteristics and vulnerable groups. As part of the engagement process, the CCG has sought to engage patients and gain feedback using the following methods:  In January 2020, Morecambe Bay CCG wrote to patients informing them of Dr. Jain’s retirement from general practice. A patient survey was enclosed with this letter. As the letter was addressed to ‘Head of Household’ and one copy of the survey sent, additional copies were made available from The Surgery and could also be completed online. The deadline for the completion of the survey was 03 February 2020.  In addition to the patient survey, a number of face-to-face Patient Engagement Events were held on the following dates: o Wednesday 22 January: 18:30 – 20:00 o Thursday 23 January: 11:00 – 12:30 o Tuesday 28 January: 14:00 – 15:30 o Wednesday 29 January: 18:30 – 20:00  A survey was also sent to neighbouring GP practice to gauge their views on the potential options and assess their capacity in the event of patient dispersal or the need for interim cover while a new provider is procured. The main feedback from patients both through the patient survey and the face-to-face engagement events were:  Lack of public transport: Patients were concerned that the lack of public transport means that it would be extremely difficult for older and/or disabled patients to travel any significant distance to access primary care services. Whilst the nearest surgery is located in Dalton, patients were concerned that there was no direct train or bus service to Dalton.  Lack of pharmacy provision in Askam in Furness: Patients were concerned that without the GP practice, there would be no access to medicines without travelling to Dalton, Barrow or Ulverston.  Lack of available places at local surgeries: Some patients reported that they have tried to register at alternative practices without success as they had been told that the lists were full. At the engagement events, patients were assured that the CCG would work with local practices to ensure that sufficient places were available locally should the decision be taken to disperse the patient list. Engagement has also taken place with staff members at The Surgery on multiple occasions. In addition, as part of understanding the viability of securing an alternative provider, the CCG undertook a market engagement exercise by publishing a ‘Request for Information’ (RFI). This notice was published via the Official Journal of the European Union (OJEU) and Contracts Finder. This process was managed by procurement experts from North East Commissioning Support Unit (NECS).

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Does the project comply with the NHS Accessible Information Standard? (providing any documents, leaflets, resources in alternative formats if requested to meet differing communication needs of patients and carers) YES

Please explain how? All NHS organisations are required to provide information in accessible formats suited to the different communication needs of patients – upon request. As good practice, an FAQ was provided which was produced in an easy read format to offer clear, easy-to-understand information to patients. Patient letters included a statement advising them how to make a request for information in an alternative format. Provision for letters to be provided in alternative languages is available through the CCG upon request.

EVIDENCE USED FOR ASSESSMENT What evidence have you considered as part of the Equality Impact Assessment?

 All research evidence base references including NICE guidance and publication– please give full reference  Bring over comments from Stage 1 and prior learning (please append any documents to support this)

Local Demographics – Barrow in Furness:

The Public Health Profile for Barrow in Furness, published by Public Health England (as of November 2019) shows that:

 The health of people in Barrow in Furness is varied compared with the England average.  Barrow in Furness is one of the 20% most deprived districts/unitary authorities in England.  Approximately 16.6% (1,975) of children live in low income families.  Life expectancy for both men and women is lower than the England average.  Life expectancy is 11.5 years lower for men and 10.5 years lower for women in the most deprived areas of Barrow in Furness than in the least deprived areas.  In Year 6, 22% (152) of children are classified as obese.  The rate of alcohol-specific hospital stays among those under 18 is 127 (per 100,000 population) – this is worse than the average for England. This represents 17 admissions per year.  Levels of teenage pregnancy, GCSE attainment and breastfeeding initiation are worse than the England average.  The rate of alcohol-related harm hospital stays in 776 (per 100,000 population) – this is worse than the England average. This represents 516 admissions per year.  The rate of self-harm hospital stays is 411 (per 100,000 population) – this is worse than the England average. This represents 264 admissions per year.  Estimates levels of adult excess weight are worse than the England average.  Rates of sexually transmitted infections and TB are better than average

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 The rates of under 75 mortality from cardiovascular diseases and under 75 mortality from cancer are worse than the England average.

The Surgery, Askam in Furness – Public Health Intelligence:

The Surgery in Askam in Furness has a registered patient population of 1,542 (Source: NHS Digital, January 2020), compared to a CCG average of 9,757 and an England average of 8,583.

The age distribution of patients shows some noticeable differences from both the CCG and England averages. The CCG age profile mostly mirrors the England average.

Life expectancy at birth for the practice population is 78.7 years for men and 83.1 years for women. The England averages of 79.5 for men and 83.1 years for women.

Further information from PHE Fingertips data sets on age distribution for The Surgery at Askam in Furness is shown below:

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Additional data on practice demographics:

No firm data about the ethnicity of the patient population of the practice is available. However, ethnicity estimates for the practice suggest that 1.0% of patients come from non-white ethnic groups (PHE Fingertips data accessed 04/02/2020).

Deprivation factors:

The population for The Surgery is in the fifth least deprived decile. The IMD score for the practice is 19.1, which is lower than both the CCG average (21.8) and the England average (21.7).

The number of registered patients aged over 65 is higher than the England average (particularly male patients) and may have a larger set of demands and experience more barriers to accessing healthcare within the context of the overall practice population.

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Summary of health inequality information amongst The Surgery patients:

 Cancer prevalence is slightly higher than the England average and comparable to the CCG average  Prevalence of high blood pressure is higher than the England average and the CCG average  Stroke prevalence is slightly higher than the England average and comparable to the CCG average  Incidences of heart failure are comparable to both the England and CCG averages.  Prevalence of diabetes is lower than both the England and CCG averages.  Rates of antibiotic prescribing are comparable to both the England and CCG averages. This suggests average overall health and timely presentation.  Prevalence of learning disabilities within the practice population is slightly higher than both the England and CCG averages.  Prevalence of poor mental health is slightly lower than both the England and CCG averages.

Neighbouring Practices:

Distance to List Size (as of Askam (in miles 1.1.1.1.1 Practice 01.10.19) by car) The Surgery, Askam in Furness 1,542 N/A Market Street Surgery (Dalton in Furness) 8,663 2.8 Duddon Valley Medical Practice (Kirkby in Furness) 3,309 5.0 Norwood Medical Practice (Barrow in Furness) 11,112 6.0 Abbey Road Surgery* (Barrow in Furness) 6,650 7.1 Risedale Surgery* (Barrow in Furness) 6,587 7.1 Atkinson Health Centre* (Barrow in Furness) 4,719 7.1 Bridgegate Medical Centre (Barrow in Furness) 8,921 6.4 Burnett Edgar Medical Centre (Barrow in Furness) 4,351 7.5 Duke Street Surgery (Barrow in Furness) 9,727 7.3 The Family Practice (Barrow in Furness) 3,186 6.4 Liverpool House Surgery (Barrow in Furness) 5,318 6.6 Dr. Johnston & Partners (Ulverston) 4,476 6.9 Dr. Murray & Partners (Ulverston) 11,113 6.9 * NB: These 3 practices have relocated to Alfred Barrow Health Centre

Distance for pedestrians from railways stations to neighbouring practices:

Distance in miles from 1.1.1.1.2 Practice Barrow Railway Station Market Street Surgery (Dalton in Furness) 0.25 Norwood Medical Practice (Barrow in Furness) 0.33 Abbey Road Surgery* (Barrow in Furness) 0.70 Risedale Surgery* (Barrow in Furness) 0.70 Atkinson Health Centre* (Barrow in Furness) 0.70

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Bridgegate Medical Centre (Barrow in Furness) 1.09 Burnett Edgar Medical Centre (Barrow in Furness) 1.82 Duke Street Surgery (Barrow in Furness) 0.65 The Family Practice (Barrow in Furness) 0.28 Liverpool House Surgery (Barrow in Furness) 1.14 Distance in miles from 1.1.1.1.3 Practice Kirkby Railway Station Duddon Valley Medical Practice (Kirkby in Furness) 0.1 Distance in miles from 1.1.1.1.4 Practice Ulverston Railway Station Dr. Johnston & Partners (Ulverston) 0.6 Dr. Murray & Partners (Ulverston) 0.6

ENSURING LEGAL COMPLIANCE

Think about what you are planning to change; and what impact that will have upon ‘your’ compliance with the Public Sector Equality Duty (refer to the Guidance Sheet complete with examples where necessary) In what way does your How might your proposal affect How will you mitigate any current service delivery help your capacity to: adverse effects? to: (You will need to review how effective these measures have been) End Unlawful End Unlawful End Unlawful Discrimination? Discrimination? Discrimination? NHS England protocol will The proposed options are Robust engagement activities be followed throughout the likely to lead to concerns from have taken place in order to process ensuring mandated current patients. The CCG is gauge the needs and requirement are followed. actively seeking ways to concerns of patients. As per the GMS contract, reduce any negative impact This assessment draws on the practice adheres to the that the potential closure or intelligence that will help to Equality Act. potential change in provider identify the needs of this may have. The CCG will group and possible barriers ensure that patients are fully that these groups face. informed of the change and choice they have in their primary care. Promote Equality of Promote Equality of Promote Equality of Opportunity? Opportunity? Opportunity? See above statement Following Dr. Jain’s notice to The CCG will carefully terminate the GMS contract, provide communications the current provision at the around the potential changes

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practice will no longer remain to inform patients and viable or sustainable unless stakeholders of the changes action is taken. Regardless of and the choice they have. the decision to either disperse In the event that a new or secure a new provider, all provider is secured, patients patients will be provided with will be given the opportunity information on how to re- to remain registered with the register at an alternative practice or to re-register with practice based on patient an alternative practice. choice. Foster Good Relations Foster Good Relations Foster Good Relations Between People Between People Between People See above statement Patients will be provided with Information: To ensure that guidance and information information is available this is about the potential changes. easy to understand.

Assurance: To have a plan in place to deal with patients that are worried about any potential changes and how this will may affect them. WHAT OUTCOMES ARE EXPECTED/DESIRED FROM THIS PROJECT?

The intended outcome of this piece of work is to ensure continued access to general medical services for all patients within Morecambe Bay including those currently registered with the Askam Practice.

How will any outcomes of the project be monitored, reviewed, evaluated and promoted where necessary?

“think about how you can evaluate equality of access to, outcomes of and satisfaction with services by different groups”

The contractual monitoring and management of General Medical Services will ensure review and monitoring of the continued delivery of general medical services to patients within Morecambe Bay. This is overseen by the Primary Care Commissioning Committee and the Primary Care Commissioning Operational Group.

The outcome of the decision in relation to whether general medical services will continue to be delivered from a site in Askam or from surrounding practices will be widely advertised to patients and the local public via a number of routes including:

 Patient letters (to registered patients of Dr Jain)  Practice posters  Notifications upon CCG website and in CCG newsletter Stakeholder briefing document

The measure of patient satisfaction for general medical services is the national GP Patient

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Survey. This is regularly reviewed as part of the standard contractual monitoring for general medical services.

OPTION 1: PRACTICE CLOSURE & DISPERSAL OF PATIENT LISTS

EQUALITY IMPACT AND RISK ASSESSMENT

Does the ‘project’ have the potential to:  Have a positive impact (benefit) on any of the equality groups?  Have a negative impact / exclude / discriminate against any person or equality group?  Explain how this was identified? Evidence/Consultation?  Who is most likely to be affected by the proposal and how (think about barriers, access, effects, outcomes etc.)  Please include all evidence you have considered as part of your assessment e.g. Population statistics, service user data broken down by equality group/protected group

Please see Equality Groups and their issues guidance document, this document may help and support your thinking around barriers for the equality groups

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect   Age Older People Working Age Young People Population

Explanation:

Older People: Age profiles on the patients currently registered at The Surgery in Askam in Furness show an above average number of patients over 70s year old – particularly male patients within this age group. Older patients within this age bracket are deemed more likely to have a long-term condition such as dementia, diabetes, cardiovascular disease and other health problems.

Patients within this age bracket that may have mobility issues and/or long-term conditions may find it difficult to access services at alternative practice sites due to the increased distance of travel required to attend appointments. The engagement findings have indicated that transport to alternative practice sites is a main concern – particularly for older people who are less likely to drive. Public transport in the area is very infrequent which may limit an older patient’s ability to secure and subsequently attend an appointment at an alternative practice. Additionally, some patients with mobility issues have indicated that they would find it difficult or unviable to walk to the local railway station – let alone walk the additional distance at the other end of the train journey to an alternative practice.

If the patient list is dispersed, the alternative practices involved should anticipate an increase in

63 requests for home visits from patients who are unable to access the practice, and should accommodate such requests where appropriate. Additionally, the practices involved should flag records to indicate where patients require flexible appointments to fit in with transport arrangements.

The above concerns are likely to be echoed regarding medicine dispensing as this was taking place via the practice. In the event of patient dispersal, patients would need to access an alternative practice or community pharmacy in order to access medicine dispensing services. Any mobilisation or communication plans should give consideration to this.

Young People: Overall, the age distribution amongst patients at The Surgery in Askam in Furness is lower than average for younger people aged 0-39. The engagement findings identified that transport is likely to be a concern for young people. As above, the practices involved should flag records to indicate where patients require flexible appointments to fit in with transport arrangements or school hours. They may also wish to consider providing telephone triage and home visits where appropriate.

The above concerns are likely to be echoed regarding medicine dispensing as this was taking place via the practice. In the event of patient dispersal, patients would need to access an alternative practice or community pharmacy in order to access medicine dispensing services. Any mobilisation or communication plans should give consideration to this.

Working Age Population: Overall, the number of patients of working age accessing services at The Surgery in Askam in Furness is lower than average. For some patients of working age, the increased distance to travel may raise the same concerns as above. However, for many patients of working age, it may be easier to access an alternative site that may be nearer to a patient’s place of work. Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Disability

Explanation:

People with a disability and/or long term conditions are likely to be concerned about this change and will need reassurance that the care that they receive will be continued.

Those people with disabilties and/or long-term conditions may find it difficult to access services at alternative practice sites due to the increased distance of travel required to attend appointments. The engagement findings have indicated that transport to alternative practice sites is a main concern. Public transport in the area is very infrequent which may limit a patient’s ability to secure and subsequently attend an appointment at an alternative practice. Additionally, some patients with mobility issues have indicated that they would find it difficult or unviable to walk to the local railway station – let alone walk the additional distance at the other end of the train journey to an alternative practice.

The above concerns are likely to be echoed regarding medicine dispensing as this was taking place via the practice. In the event of patient dispersal, patients would need to access an alternative practice or community pharmacy in order to access medicine dispensing services. Any

64 mobilisation or communication plans should give consideration to this.

The Surgery at Askam in Furness’ population of patients with a learning disability is slightly higher than the England average. In the event of patient dispersal, this assessment recommends that easy read and plain English communication is available to help all people understand the changes and the choice that they have. As per the section relating to older people, alternative practices should flag the needs of these patients and be able to provide home visits and telephone triage where appropriate.

Large print resources should be available for people with visual impairments (see above section re: older people).

The issue of mobility and access is likely to be a concern for people with reduced mobility who may be concerned that alternative sites are not accessible.

Although all NHS GP practices should be disability compliant, this should be communicated to patients with information on parking, access through public transport and the location of any alternative sites in the event of patient dispersal.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Gender Reassignment Explanation:

Transgender patients tend to build a good relationship with their designated GP who provides their care. The mobilisation plan should consider these patients if the patient list is dispersed to ensure that there is a smooth continuation of care.

There is no current data available on the number of Askam Surgery patients who are transgender or are undergoing gender reassignment. National data suggests that between 0.1-0.5% of the national population identify as trans.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Pregnancy and Maternity

Explanation:

Patients that are pregnant or have recently given birth will be cared for by a number of health professionals including their GP. All registered patients with GP practices in Morecambe Bay will have access to pregnancy and maternal services irrespective of their registered GP. Patients are able to choose to register with practices that have female clinicians if this is their personal preference. Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Race

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Explanation:

No patient data is available regarding the race of patients at Askam Surgery. However, ethnicity estimates suggest that 1.0% of patients belong to non-white ethnic groups (Public Health Fingertips data). Of the survey respondents, 96% of patients responded to this question with 99% of respondents identifying as white.

Any changes may impact upon this group is their communication needs are not considered. During the engagement period, the CCG offered to provide materials in alternative languages if required. This should also be considered within any mobilisation plans relating to patient dispersal.

Any alternative practices involved in the patient dispersal exercise should ensure that a chaperone service is available.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Religion or Belief

Explanation:

There is no available data on the religion of the patient population of Askam Surgery. There should not be any adverse impact upon any group holding a particular belief.

Any alternative practices involved in the patient dispersal exercise should ensure that a chaperone service is available.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Sex (Gender)

Explanation:

There should be no adverse impact on either sex.

Any alternative practices involved in the patient dispersal exercise should ensure that a chaperone service is available.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Sexual Orientation

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Explanation:

There is no data on how many patients at Askam Surgery are LGB (lesbian, gay or bisexual). Of the survey respondents, 93% identified as heterosexual. Only 97% of patients answered this question; less than 1% identified as being homosexual; less than 1% identified as being bisexual whilst the remainder of patients either preferred not to say or responded to the other category.

There should be no adverse impact upon this group, however national research suggests that LGB&T people accessing routine healthcare services often feel that their needs and health inequalities are misunderstood or overlooked by clinicians.

While this group should not be disadvantaged due to their characteristic, any mobilisation plan will need to consider their needs and ensure that they are aware of services (including screening programmes).

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Marriage and Civil

Partnership N.B. Marriage & Civil Partnership is only a protected characteristic in terms of work-related activities and NOT service provision Explanation:

This group should not be impacted by this change.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect   Carers

Explanation:

Public Health data states that 20.1% of Askam Surgery patients provide unpaid care compared to an England average of 16.9% and a CCG average of 16.4%.

This change should not affect carers adversely. However, they will need to be informed of the changes. This could be supported by stakeholders which provide information and support to carers.

Carers are likely to have concerns regarding access and travelling to alternative practice sites, particularly relating to distance and cost – any information disseminated should give assurances to these concerns.

Additionally, if it is the carer themselves that wishes to access primary care services, the increased distance and time may have a negative impact upon making alternative care arrangements for their care, or may incur further costs if they need to bring the person receiving care with them to an appointment.

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The above concerns are likely to be echoed regarding medicine dispensing as this was taking place via the practice. In the event of patient dispersal, patients would need to access an alternative practice or community pharmacy in order to access medicine dispensing services. Any mobilisation or communication plans should give consideration to this.

As above, alternative practices involved in the patient dispersal should flag records to indicate where patients require flexible appointments to fit in with transport arrangements, and ensure that telephone triage and home visits are available where appropriate.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Deprived Communities

Explanation:

The population for Askam Surgery is in the fifth least deprived decile. The IMD score for the practice is 19.1, which is slightly lower than the CCG average (21.8) and the England average (21.7).

There is a recognised link between deprivation and poorer health outcomes. This group is more likely to have poorer education outcomes and may have lower literacy rates. This needs to be considered in any communication work.

The increased distance, infrequency of public transport and increased cost of travelling to alternative sites may be a concern to some people from these groups. As above, alternative practices involved in the patient dispersal should flag records to indicate where patients require flexible appointments to fit in with transport arrangements, and should ensure that telephone triage is available.

The above concerns are likely to be echoed regarding medicine dispensing as this was taking place via the practice. In the event of patient dispersal, patients would need to access an alternative practice or community pharmacy in order to access medicine dispensing services. Any mobilisation or communication plans should give consideration to this.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Vulnerable Groups e.g.

Asylum Seekers, Homeless, Sex Workers, Military Veterans, Rural communities.

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Explanation:

Vulnerable groups face significant barriers to accessing services (Healthwatch reports, MLCSU Asylum Seekers guidance document, etc).

The needs of vulnerable people should be considered within any mobilisation or communication plans.

Informing vulnerable groups about any changes in their primary care could be supported through stakeholder groups and agencies that support vulnerable people.

For vulnerable patients that wish to register elsewhere, it should be made easy and without barriers.

Although these groups are not protected under the Equaltiy Act (2010), they are given protection under the Health and Social Care Act and the Human Rights Act.

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OPTION 2: PROCUREMENT OF A NEW PROVIDER

EQUALITY IMPACT AND RISK ASSESSMENT

Does the ‘project’ have the potential to:  Have a positive impact (benefit) on any of the equality groups?  Have a negative impact / exclude / discriminate against any person or equality group?  Explain how this was identified? Evidence/Consultation?  Who is most likely to be affected by the proposal and how (think about barriers, access, effects, outcomes etc.)  Please include all evidence you have considered as part of your assessment e.g. Population statistics, service user data broken down by equality group/protected group

Please see Equality Groups and their issues guidance document, this document may help and support your thinking around barriers for the equality groups

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect   Age Older People Older People

Explanation:

Askam Surgery serves a registered population of 1,542 patients. The number of registered patients aged over 65 is higher than average – particularly for male patients.

Under this proposal, the CCG would aim to procure a new service provider to deliver services to the registered population of Askam Surgery.

Older People: Some patients may be concerned about continuity of care as a result of the change in provider. This may be of particular concern to older people or people with disabilities and/or long-term conditions. The patients’ medical records will be made available to the new provider. This will support continuity of care. Additionally, it is likely that staff, including remaining clinical staff will be eligible to TUPE to the new provider. This will provide further continuity of care.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Disability

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Explanation:

People with a disability and/or long term conditions are likely to be concerned about this change and will need reassurance that the care that they receive will be continued. The patients’ medical records will be made available to the new provider. This will support continuity of care. Additionally, it is likely that staff, including remaining clinical staff will be eligible to TUPE to the new provider. This will provide further continuity of care.

Large print resources should be available for people with visual impairments (see above section re: older people).

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Gender Reassignment Explanation:

Transgender patients tend to build a good relationship with their designated GP who provides their care. The mobilisation plan should consider these patients if the patient list is dispersed to ensure that there is a smooth continuation of care.

There is no current data available on the number of Askam Surgery patients who are transgender or are undergoing gender reassignment. National data suggests that between 0.1-0.5% of the national population identify as trans.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Pregnancy and Maternity

Explanation:

There should be no disproportionate impact upon this group.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Race

Explanation:

No patient data is available regarding the race of patients at Askam Surgery. However, ethnicity estimates suggest that 1.0% of patients belong to non-white ethnic groups (Public Health Fingertips data). Of the survey respondents, 96% of patients responded to this question with 99% of respondents identifying as white.

Any changes may impact upon this group is their communication needs are not considered. During the engagement period, the CCG offered to provide materials in alternative languages if required. The same will apply regarding any potential change in provider.

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Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Religion or Belief

Explanation:

There is no available data on the religion of the patient population of Askam Surgery. There should not be any adverse impact upon any group holding a particular belief.

Any alternative providers should ensure that a chaperone service is available.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Sex (Gender)

Explanation:

There should not be any disproportionate impact upon this group or any gender in particular as a result of a change in provider.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Sexual Orientation Explanation:

There is no data on how many patients at Askam Surgery are LGB (lesbian, gay or bisexual). Of the survey respondents, 93% identified as heterosexual. Only 97% of patients answered this question; less than 1% identified as being homosexual; less than 1% identified as being bisexual whilst the remainder of patients either preferred not to say or responded to the other category.

There should be no adverse impact upon this group, however national research suggests that LGB&T people accessing routine healthcare services often feel that their needs and health inequalities are misunderstood or overlooked by clinicians.

While this group should not be disadvantaged due to their characteristic, any mobilisation plan will need to consider their needs and ensure that they are aware of services (including screening programmes).

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect

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 Marriage and Civil

Partnership N.B. Marriage & Civil Partnership is only a protected characteristic in terms of work-related activities and NOT service provision Explanation:

There should be no disproportionate impact upon this group.

Protection under this characteristic only applies for work related activities (not service provision).

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Carers

Explanation:

Public Health data states that 20.1% of Askam Surgery patients provide unpaid care compared to an England average of 16.9% and a CCG average of 16.4%.

This change should not affect carers adversely. However, they will need to be informed of the changes. This could be supported by stakeholders which provide information and support to carers.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Deprived Communities

Explanation:

The population for Askam Surgery is in the fifth least deprived decile. The IMD score for the practice is 19.1, which is slightly lower than the CCG average (21.8) and the England average (21.7).

There is a recognised link between deprivation and poorer health outcomes. This group is more likely to have poorer education outcomes and may have lower literacy rates. This needs to be considered in any communication work.

Equality Group / Positive effect Negative Neutral /Indirect effect Protected Group effect  Vulnerable Groups e.g.

Asylum Seekers, Homeless, Sex Workers, Military Veterans, Rural communities.

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Explanation:

Vulnerable groups face significant barriers to accessing services (Healthwatch reports, MLCSU Asylum Seekers guidance document, etc).

The needs of vulnerable people should be considered within any mobilisation or communication plans.

Informing vulnerable groups about any changes in their primary care could be supported through stakeholder groups and agencies that support vulnerable people.

For vulnerable patients that wish to register elsewhere, it should be made easy and without barriers.

Although these groups are not protected under the Equaltiy Act (2010), they are given protection under the Health and Social Care Act and the Human Rights Act.

SECTION 3 - COMMUNITY COHESION & FUNDING IMPLICATIONS Does the ‘project’ raise any issues for Community Cohesion (how it will affect people’s perceptions within neighbourhoods)?

None currently identified.

What effect will this have on the relationship between these groups? Please state how relationships will be managed?

The CCG will work the practice, patients, carers and surrounding practices in order to fully understand their needs and engage them in any proposed changes to service delivery.

The CCG will develop robust communication and engagement plans once a preferred option has been identified.

This EIRA will be updated following the development of the communication and engagement plan and throughout the mobilisation period.

Does the proposal / service link to QIPP (Quality, Innovation, Productivity and Prevention Programme)? No

Does the proposal / service link to CQUIN (Commissioning for Quality and Innovation)? No

What is the overall cost of implementing the ‘project’? Please state: Cost & Source(s) of funding: Detailed costing are available in the paper presented to Primary Care Commissioning Committee on 18th February 2020.

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This is the end of the Equality Impact section, please use the checklist in Appendix 2 to ensure and reflect that you have included all the relevant information.

SECTION 4 - HUMAN RIGHTS ASSESSMENT If the Stage 1 Equality Impact and Risk Assessment highlighted that you are required to complete a Stage 2 Human Rights assessment (please request a stage 2 Human Rights Assessment from the Equality and Inclusion Team), please bring the issues over from the screening into this section and expand further using the Human Rights full assessment toolkit then email to equality and inclusion team.

SECTION 5 – RISK ASSESSMENT See guidance document for step by step guidance for this section Risk Matrix. Use this table to work out the risk score

RISK MATRIX Risk level Consequence level RARE 1 UNLIKELY 2 POSSIBLE 3 LIKELY 4 VERY LIKELY 5 1. Negligible 1 2 3 4 5 2. Minor 2 4 6 8 10 3. Moderate 3 6 9 12 15 4. Major 4 8 12 16 20 5. Catastrophic 5 10 15 20 25 Consequence Score: Likelihood Score: Enter risk Risk score = consequence x likelihood score here

Example: risk of not consulting patients leading to legal challenge: 20 Consequence score of 5 and Likelihood score of 4 Any comments / records of different risk scores over time (e.g. reason for any change in scores over time): 6

Important: If you have a risk score of 9 and above you should escalate to the organisations risk management procedures.

EQUALITY IMPACT AND RISK ASSESSMENT AND ACTION PLAN

Risk identified Actions required to Resources Who will Target reduce / eliminate required (this lead on the date negative impact may include action? financial) Example: Consult with people with protected Consultation and Comms and 01/01/20 A proposal to decommission a characteristics who may be directly or engagement plan. Engagement – 17 service has not adequately indirectly affected by the proposal. To A. Body consulted with protected show understanding of the issues that

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groups therefore lead s to a may affect protected groups in risk to both the proposal and relation to the proposal. the organisation through risk of legal challenge and/or Judicial Review. There is a risk that any CCG has undertaken a 2 week Commissioning CCG procurement process may RFI period to identify potential and Procurement not be successful in providers. CCG will work in close Strategy securing a new provider for collaboration with NHSE and the longer term Procurement with a view to delivering an effective process. Work with patient, stakeholders and the provider market to fully understand requirements with a view to ensuring the service offer is attractive. Concern and uncertainty Robust communications, Comms and CCG may lead to complaints engagement and mobilisation Engagement Plan from patients and carers plans Older patients/disabled Alternative practices involved in Primary Care CCG patients/carers/deprived dispersal to have appropriate Team / Alternative communities may find it measures in place – i.e. flagging practices difficult or impossible to patient needs, home visits, travel to alternative telephone triage, flexible practice sites in the event appointments of dispersal.

Possible risk of increased Communication and information Comms and CCG use of wider healthcare to be clear on arrangements Engagement Plan services including throughout the process. secondary care as a result of uncertainty If going to procurement, a caretaker provider to be in place to ensure continuity.

Regular contract and quality review meetings with new provider.

Monitor possible impact on wider health care services with a view to early identification of any issues. SECTION 6 – EQUALITY DELIVERY SYSTEM 2 (EDS2)

Please go to Appendix 1 of the EIRA and tick the box appropriate EDS2 outcome(s) which this project relates to. This will support your organisation with evidence for the Equality and Inclusion annual equality progress plan and provide supporting evidence for the annual Equality Delivery System 2 Grading SECTION 7 – ONGOING MONITORING AND REVIEW OF EQUALITY IMPACT RISK ASSESSMENT AND ACTION PLAN

Please describe briefly, how the equality action plans will be monitored through internal CCG governance processes?

These will be monitored via Primary Care Commissioning Operational Group and the Primary Care Commissioning Committee.

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Date of the next review of the Equality Impact Risk Assessment section and action plan? (Please note: if this is a project or pilot, reviews need to be built in to the project/pilot plan)

2nd April 2020

Which CCG Committee / person will be responsible for monitoring the action plan progress?

Primary Care Commissioning Team and Primary Care Commissioning Committee. FINAL SECTION SECTION 8 Review date linked to Commissioning Cycle: 2nd April 2020

Acknowledgement that EIRA will form evidence for NHS Standard Contract Schedule 13: N/A Date sent to Equality & Inclusion (E&I) Team for quality check: 11/02/20

Date quality checked by Equality and Inclusion Business Partner: 11/02/20

Date of final quality check by Equality and Inclusion Business Partner: 11/02/20

Signature Equality and Inclusion Business Partner: email signature provided.

CCG Committee Name and sign off date: Primary Care Commissioning Committee 18th February 2020.

This is the end of the Equality Impact and Risk Assessment process: By now you should be able to clearly demonstrate and evidence your thinking and decision(s). To meet publishing requirements this document SHOULD NOW BE PUBLISHED ON YOUR ORGANISATIONS WEBSITE.

• Save this document for your own records. Send this documents and copy of Human Rights Screening to [email protected]

Supplementary information to support CCG compliance to equality legislation:

Appendix 1: Equality Delivery System: APPENDIX 1: The Goals and Outcomes of the Equality Delivery System Tick Objective Narrative Outcome box(s) below 1. The NHS 1.1 Services are commissioned, procured, Better health should achieve designed and delivered to meet the health outcomes improvements needs of local communities in patient 1.2 Individual people’s health needs are health, public assessed and met in appropriate and health and effective ways patient safety 1.3 Transitions from one service to another,

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for all, based for people on care pathways, are made on smoothly with everyone well-informed comprehensive 1.4 When people use NHS services their evidence of safety is prioritised and they are free from needs and mistakes, mistreatment and abuse results 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities 2. The NHS 2.1 People, carers and communities can Improved should improve readily access hospital, community health or patient access accessibility primary care services and should not be and experience and denied access on unreasonable grounds information, 2.2 People are informed and supported to be and deliver the as involved as they wish to be in decisions right services about their care that are 2.3 People report positive experiences of the targeted, NHS useful, useable 2.4 People’s complaints about services are and used in handled respectfully and efficiently order to improve patient experience 3. The NHS 3.1 Fair NHS recruitment and selection A should increase processes lead to a more representative representative the diversity workforce at all levels and supported and quality of 3.2 The NHS is committed to equal pay for workforce the working work of equal value and expects employers to lives of the paid use equal pay audits to help fulfil their legal and non-paid obligations workforce, 3.3 Training and development opportunities supporting all are taken up and positively evaluated by all staff to better staff respond to 3.4 When at work, staff are free from abuse, patients’ and harassment, bullying and violence from any communities’ source needs 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce 4. NHS 4.1 Boards and senior leaders routinely Inclusive organisations demonstrate their commitment to promoting leadership should ensure equality within and beyond their organisations that equality is 4.2 Papers that come before the Board and everyone’s other major Committees identify equality- business, and related impacts including risks, and say how everyone is these risks are managed expected to 4.3 Middle managers and other line take an active managers support their staff to work in

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part, supported culturally competent ways within a work by the work of environment free from discrimination specialist equality leaders and champions

Equality Impact and Risk Assessment Checklist Scope Yes/No Have I made the reader aware of the full scope of the proposal and do I understand the current situation and what changes may occur? Legal Have I made the reader aware of our organisations legal duties with regard to Equality & Diversity and are they documented? Has the relevance of these duties pertaining to this item been outlined explicitly and documented? Have I explained how in this area we currently meet our Public Sector Equality Duties and how any change may affect this? Information Have I seen sufficient research and consultation to consider the issues for equality groups? (This may be national and local; demographic, numbers of users, numbers affected, community needs, comparative costs etc.) Have I carried out specific consultation with affected groups prior to a final decision being made? Has consultation been carried out over a reasonable period of time i.e. no less than six weeks leading up to this item? Have I provided evidence that a range of options or alternatives have been explored? Impact Do I understand the positive and negative impact this decision may have on all equality groups? Am I confident that we have done all we can to mitigate or at least minimise negative impact for all equality groups? Am I confident that where applicable we considered treating disabled people more favourably in order to avoid negative impact (Disability Equality Duty)? Am I confident that where applicable we allowed an exception to permit different treatment ( i.e. a criteria or condition) to support positive action Have I considered the balance between; proposals that have a moderate impact on a large number of people against any severe impact on a smaller group. *Wider Budgetary Impact (where applicable) Within the wider context of budgetary decisions did I consider whether an alternative would have less direct impact on equality groups? Within the wider context of budgetary decisions did I consider whether particular groups would be unduly affected by cumulative effects/impact? Transparency of decisions Will there be an accurate dated record of the considerations and decisions made and what arrangements have been made to publish them? Due regard Did I consider all of the above before I made a recommendation/decision?

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Appendix 2: Checklist for ensuring you have considered public sector equality duty and included all relevant information as part of the EIRA.

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