Improving Healthcare Together 2020-2030 Integrated Impact Assessment Appendices 1 June 2020

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Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment Appendices

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Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment Appendices

Contents

A. Governance 8 A.1 Integrated Impact Assessment Steering Group 8 A.2 Travel and Access Working Group 14

B. Stakeholder engagement 18 B.1 Stakeholder engagement plan 18 B.2 Screener questions for focus groups 30 B.3 Focus group discussion guide 39 B.4 Note on focus group recruitment 54 B.5 Delivery of additional engagement 58 B.6 Solutions workshop 59

C. Air Quality Assessment Methodology 64

D. Green House Gases Assessment Methodology 73

E. Travel and Access Methodology 75 E.1 Technical note on travel and access methodology 75 E.2 Key questions 79

F. Background data collected for travel and access analysis 82 F.1 Data sources 82 F.2 Utilisation maps 85 F.3 Hospital catchment maps 96 F.4 Deprivation analysis maps 108 F.5 Study area maps 109 F.6 Parking costs 111

G. Travel and access baseline data 112 G.1 Demographic density maps 112

H. Results of travel and access analysis 118 H.1 Improving Health Together – Travel and Access Analysis: Blue Light Ambulance 118 H.2 Improving Health Together – Travel and Access Analysis: Car 118 H.3 Improving Health Together – Travel and Access Analysis: Public Transport 118

I. Initial Equality Scoping Report 119

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Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment Appendices

J. Public Sector Equality Duty (PSED) 120

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IHT Appendices to the Final Report 8 1 June 2020

A. Governance

A.1 Integrated Impact Assessment Steering Group

Integrated Impact Assessment Steering Group

Terms of Reference

 Purpose of this document

This document details the Terms of Reference (ToR) for the IHT Programme Integrated Impact Assessment Steering Group (IIASG) which forms part of the governance structure for Improving Healthcare Together 2020-2030.

An Integrated Impact Assessment (IIA) aims to (a) analyse the consequences of a reconfiguration option(s), and (b) produce evidence-based recommendations to maximise positive impacts, and minimise the negative impacts, of an option(s). The output is a series of full written reports.

 Role of the Group

The IIASG is established to provide advice to the Programme. It will agree the IIA scope and oversee and scrutinise the IIA work programme to ensure delivery against key milestones and the final IIA.

The IHT Programme will be asking the members of the IIASG to undertake the following tasks:  Review and agree the IIA scope.  Agree membership for Travel and Access Working Group.  Review the interim impact assessment report  Review the final impact assessment report taking account of recommendations from the public consultation for submission to the IHT Programme along with the IHT Programme decision making business case (DMBC).

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 Responsibilities

Responsibilities of the IIASG is to: 1. Fulfil its role as set out above. 2. Request responsible owners to support and input into the constituent parts of the IIA. 3. Provide critical response on the methodology and findings of the IIA, including on the validity of data sources. 4. Represent patients and members of the public in the IIA process, paying particular attention to protected groups as outlined in the Equality Act 2010. 5. Endorse a sector-wide view and not an organisation-specific view. 6. Adhere to the IHT Programme’s communications strategy: a. Key stakeholders are briefed and involved in at each key milestone of the programme b. Co-production will involve the community at each stage in the process, testing out assumptions and emerging thinking. c. We will specifically engage with seldom heard groups, deprived communities, carers, protected characteristic groups and service users to ensure that activities and events are inclusive. This will include working with voluntary organisations to engage through their networks and creating events designed for a specific audience. d. Specific consideration is given to the impact of any potential changes on groups protected under the Equality Act 2010. 7. Provide the communication link between the IIA and the organisation represented at the IIASG. It is the duty of members to ensure that their organisations are fully briefed about all aspects of the IIA.

 Membership of the Group

Standing members of the IIASG will include from:

Member Expertise

Responsible for the running of meetings and An Independent chair (recruited by the main point of contact for members, and programme) external scrutiny of the process as set out by Mott MacDonald

To provide an oversight on the programme’s IHT Programme representatives aim, objectives and activities, to respond to programme queries (if requested)

Mott MacDonald representatives Technical advisors on the IIA process

Public Health representatives (Merton, Sutton Health and equality impacts and Surrey)

Local Authority representation (Merton, Health, equality, travel and sustainability Sutton and Surrey) impacts

Clinical Commission Group representatives Health, equality, travel and sustainability (Merton, Sutton and Surrey) impacts

IHT Appendices to the Final Report 10 1 June 2020

Health an equality impact and stakeholder Voluntary sector representatives engagement

Health and equality impacts and community Healthwatch (Merton, Sutton and Surrey) engagement

Representative of the Travel and Access Travel and access impacts Working Group

Briefed deputies can be nominated from standing members of the steering group.

A more detailed list of the programme members can be found in the appendix.

 Decision-Making

The Steering Group will aim for a consensus on the quality assurance of the deliverables.

 Accountability

The IIASG will submit regular updates to the Programme team.

The IIASG will provide updates to the stakeholder reference group (SRG) as requested

The day to day management of the integrated impact assessment is held and administered by the Senior Programme Manager of the IHT.

 Frequency of Meetings

It is expected that the IIASG will need to sit in conjunction with a number of programme milestones. These are:  Review and agreement of terms and reference and project scope.  Interim progress update.  Submission of interim assessment report prior to the start of the public consultation (to be confirmed by the steering group).  Submission of the final impact assessment report.

The IIASG will be called to sit at dates appropriate to the delivery of these report submissions. Additional meetings are to be held where there is a particular need to engage members.

 Governance The IIA Steering Group will convene a Travel and Access Working Group with their remit as defined in the scoping document. The terms of reference for the Travel and Access Working Group will be developed and agreed by the IIA steering group and its membership.

 Confidentiality

The working assumption is that all materials disclosed at the meetings are confidential unless specifically stated. While some material may be made publicly available over the due course of their working, unless it has been stated that the workings and/or briefings can be discussed or shared publicly, all Group members have a duty of confidentiality. The person disclosing such information to the Group is responsible for identifying when material will no longer be

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confidential at the time it is given. Any challenge to the confidentiality of information given to the Group will be referred to the Programme Board for review.

The agenda and notes of the IIASG meetings will be published on the Improving Healthcare Together website – here – following sign off by the steering group.

IHT Appendices to the Final Report 12 1 June 2020

APPENDICES

Appendix A: Membership

Name Job role Organisation representing

Prof Andrew George Independent Chair of the N/A IIASG

Andrew Demetriades Programme Director IHT Programme

Charlotte Keeble Senior Programme Manager IHT Programme

Jaishree Dholakia Patient and Public IHT Programme Engagement Lead

Ioana Miron Project Support Officer IHT Programme

Brian Niven Technical Principle (IIA Mott MacDonald Director)

Hattie Fowler Senior Consultant (IIA Mott MacDonald Manager)

James Blythe Managing Director Merton & Wandsworth CCGs

Russell Hills Clinical equalities lead Surrey Downs CCG

Fiona Gaylor Head of Engagement and Merton & Wandsworth CCGs Equalities

Satvinder Buttar Equality Lead Sutton CCG

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Dr Imran Choudhury Director of Public Health Sutton Council

Iona Lidington Director of Public Health Kingston upon Thames London Borough Council

Hannah Doody Director of Community and Merton Council Housing

Stephen Taylor Director of Adult Social Royal Borough of Kingston Services and Community upon Thames Housing (DASS)

Kate Scribbins Chief Executive Healthwatch Surrey

Dave Curtis Chief Executive Healthwatch Merton

Nicola Upton Chief Executive Age UK Sutton

Dorothy Watson Chief Executive Sunnybank Trust

Naomi Martin Director Commonside Community Development Trust

Marta Ricardo Rocco Community Engagement Volunteer Centre Sutton Coordinator

Sabitri Ray Project Director Ethnic Minority Centre

Hazel Davies Home Start Manager – Home Start Epsom

Yasmin Broome Events co-ordinator Surrey coalition

Pippa Barber/Susan Gibbin Lay person Sutton

Clare Gummett Lay person Merton

IHT Appendices to the Final Report 14 1 June 2020

A.2 Travel and Access Working Group

Integrated Impact Assessment: Travel and Access Working Group

Terms of Reference

1. Purpose of this document

This document details the Terms of Reference (ToR) for the IHT Programme Integrated Impact Assessment (IIA) Travel and Access Working Group.

An IIA aims to (a) analyse the consequences of a reconfiguration option(s), and (b) produce evidence-based recommendations to maximise positive impacts, and minimise the negative impacts, of an option(s). As part of the IIA, a full travel impact assessment (TIA) will be conducted. This will focus on the travel and access consequences of reconfiguration, positive and negative travel impacts and mitigations.

The output will consist of travel impact assessment chapters in the interim IIA and the final IIA reports.

2. Role of the Group The IHT Programme will be asking the members of the group to undertake the following tasks:  Review and sign off the methodology of the travel impact assessment  Agreement to the travel impact assessment and the identified anticipated travel impacts.  Provide input to potential travel mitigations.  Provide the communication link between the TIA and the organisations represented at the group. When appropriate it is the duty of members to ensure that their organisations are fully briefed about all aspects of the IIA. The group is established to provide advice to the Programme and will report into the Integrated Impact Assessment Steering Group on a monthly basis.

A member of the Travel and Access Working Group will sit on the Integrated Impact Assessment Steering Group.

3. Responsibilities

Responsibilities of the Travel and Access Working Group include:

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 To fulfil its role as set out above.  To provide critical response on the methodology and findings of the TIA, including on the validity of data sources.  To endorse a sector-wide view and not an organisation-specific view.  To adhere to the IHT Programme’s communications strategy: - Key stakeholders are briefed and involved at each key milestone of the programme - Co-production will involve the community at each stage in the process, testing our assumptions and emerging thinking - We will specifically engage with seldom heard groups, deprived communities, carers, protected characteristic groups and service users to ensure that activities and events are inclusive. This will include working with voluntary organisations to engage through their networks and creating events designed for a specific audience. - Specific consideration is given to the impact of any potential changes on groups protected under the Equality Act 2010.

4. Membership of the Group

Members to include representation from:  Independent chair  Local Authority representation (Merton, Sutton and Surrey)  Representative from Epsom and St.Helier University Hospital Trust  Voluntary sector (from the combined geographies)  Ambulance Service representation from the London Ambulance Service and South East Coast Ambulance Service.  Transport for London  IHT programme team  PA consulting (technical experts)

5. Accountability

The group will submit its recommendations to the Integrated Impact Assessment Steering Group.

The group will provide updates to Stakeholder Reference Group as required.

The day to day management of the Group is held and administered by the programme team.

6. Frequency of Meetings

It is expected that the group will need fortnightly meetings commencing from the end of January. This will enable the group to fulfil its obligations and align with the following programme deliverables:  Submission of pre-consultation interim report prior to the start of the public consultation in early June (to be confirmed by the steering group)  Submission of any amended analysis following consultation  Submission of the final impact assessment report within a month of public consultation finishing (to be confirmed by the steering group) Additional meetings are to be held where there is a particular need to engage members.

7. Confidentiality

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8. Programme interdependencies

Figure 1: Programme governance structure organogram

IHT Appendices to the Final Report 17 1 June 2020

APPENDIX A - Working group members

Name Job role Organisation representing

Andrew Programme Director IHT programme team Demetriades

Charlotte Keeble Senior Programme Manager IHT programme team

Brian Niven Project Principle Mott MacDonald

Craig Walley Technical lead Mott MacDonald

Hattie Fowler Project Manager Mott MacDonald

Ashley Field Senior Transport Officer Surrey County Council

Chris Chowns Transport Planning Project Merton Council Officer

Eric Munro Associate Director, Estates Epsom and St Helier University and Facilities Operations, Hospitals NHS Trust Trust wide

Ian Price Tram Leader Strategy and Kingston and Sutton Shared Commissioning Environment Service

James Glossop Technical Expert PA Consulting

Lucy Simpson Principal Technical Planner Transport for London

Phil Crockford Principal Policy Officer London Borough of Sutton (Environment, Housing and Regeneration Directorate)

Rory Collinge Strategy and Partnership South East Coast Ambulance Service Manager NHS Foundation Trust

Chris Neely Stakeholder Engagement London Ambulance Service NHS Manager Trust

Simon Williams Clinical Director for Urgent NHS Surrey Downs CCG Care and Integration

IHT Appendices to the Final Report 18 1 June 2020

B. Stakeholder engagement

B.1 Stakeholder engagement plan

Technical Note

Project: Integrated Impact Assessment (IIA): Improving Healthcare Together (IHT) 2020-2030

Prepared by: Hattie Fowler Date: 14 March 2019

Approved by: Brian Niven Checked by: Brian Niven

Subject: Community engagement plan (Phase 2)

B.1.1 Purpose of the technical note This technical note has been prepared for the IIA Steering Group (IIASG) to provide an overview of phase 2 engagement and to seek their approval in this approach.

B.1.2 Overview The IIA consists of three stages, highlighted in the diagram below.

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As the diagram highlights, phase 1 of the IIA work has been completed and published. This includes:

 Stakeholder engagement with clinicians and community groups  An initial equalities analysis  A baseline travel analysis  A deprivation impact analysis report  Stakeholder engagement with protected characteristic and equalities groups In phase two further engagement will take place including 12 focus groups with people representing protected characteristics. The rest of this technical note outlines the approach to the focus groups.

B.1.3 Focus groups

B.1.3.1 Findings from the initial equalities analysis  Stakeholder engagement as part of Phase 1 covered qualitative in-depth telephone interviews with 18 individuals. These individuals described the ways in which services are used. They also reflected on the potential impact any service change could have on the local community, specifically those who fall under protected characteristics. These interviews were undertaken with: ○ 12 clinicians and CCG representatives who described the local context and provided their experiences of delivering services. ○ 6 representatives of key user groups who discussed the potential impact of any changes to acute services for those they represent As part of the phase 1 of the IIA, Mott MacDonald completed an initial equality analysis of the proposed service changes to determine which demographic groups may experience a disproportionate or differential need for major acute services 1. The demographic groups identified by the initial analysis as having a disproportionate or differential need are as follows:

1 Please note that scoping report is not yet finalised and may be revised following engagement with clinicians and/or additional information supplied to Mott MacDonald from IHT

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 Those aged 16 years old or younger  Those aged 16 - 24 years old  Those aged 65 years old or older  Disabled people  Transgender people  Pregnant women  People from a BAME background  Males  Females  People who are lesbian, gay and bisexual (LGB)  People from deprived communities The focus groups will use these findings to identify protected characteristics for participants. The focus groups will:

1. Sense check the perceived needs and impacts from phase one 2. Determine any unconsidered impacts or potential impacts including locality specific impacts

B.1.3.2 Focus group methodology Twelve focus groups will be conducted; four in each of the CCG areas.

Each focus group will aim to consist of 8-12 participants and will be convened by an experienced facilitator.

The times of the focus groups will vary with the majority occurring in the evening with times set to allow sufficient time for people to attend after work. However, reflecting on discussion with the IIA Steering Group, two groups, those with older people and those living in areas of high deprivation, have been moved to afternoon sessions. It was felt by the steering group that people from areas of high deprivation may not always work typical 9am-5pm jobs, for example shift work, and therefore require more flexibility in the timing of the groups. An afternoon session is also being offered to older participants to reflect the potential for a preference to undertake activities in the afternoon.

If any focus group fails to recruit less than the quota required, then consideration will be given as to whether another group will be recruited or whether the data will be acceptable. That decision will be made by the Integrated Impact Assessment Steering Group Independent Chair taking into account factors such as the size of the focus group and how well that population have been involved in other groups and whether it is likely that additional information would be obtained.

Table.1 details the location, time, composition and rationale for each focus group. It is important that IIA engagement is intelligence led, and the rationale column sets out the justification for each focus group.

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Table 1 – Composition of focus groups CCG Location Time Composition Wards of Rationale highest density Merton Colliers Wood Library, 18:30- Females aged 18- Figge’s Marsh There is evidence that BAME mothers have a disproportionate need for Colliers Wood High St, 20:00 44, from a BAME Graveney major acute services, due to increased risk of maternal death. London SW19 2HR background Longthornton In Merton, 60% of babies were born to women born outside the UK. Babies from South Asian and Black Caribbean backgrounds are twice as likely to die before their first birthday compared to babies from White British backgrounds, highlighting a disproportionate need. Colliers Wood Library, 20:15- People from a Figge’s Marsh There is evidence that people from a BAME background have a Colliers Wood High St, 21:45 BAME background Gravney disproportionate need for major acute services, especially South Asian London SW19 2HR and African Caribbean demographics. Colliers Wood There is an especially high population of individuals from BAME backgrounds in Merton (52%) compared to the UK average (20%). South Asian and African Caribbean demographics are statistically more likely to have emergency admissions due to respiratory and cardiovascular disease then White British populations, highlighting a disproportionate need. An IHT equalities engagement found that a lack of sensitivity of language and cultural requirements for care in less diverse areas (such as Surrey Downs) is a major issue concerning proposed service changes. Commonside community 18:30- People from Pollards Hill There is evidence that people from deprived communities have a Development Trust: New 20:00 deprived Cricket Green disproportionate need for major acute services. Horizon centre, South communities Figge’s Marsh In Merton, levels of deprivation are concentrated in small areas of high Lodge avenue, Pollards Hill, density, with 3% of the total population in the most deprived quintile Mitcham, CR4 1LT nationally. Deprived individuals are disproportionately impacted by increased travel costs associated with proposed service changes. This was cited as a major issue during an IHT equalities engagement. Commonside community 20:15- People with a Figge’s Marsh There is evidence that people with LLTI have a disproportionate need Development Trust: New 21:45 Limiting Long-Term Graveney for major acute services. Horizon centre, South Illness (LLTI) St.Helier There is an especially high density of individuals with LLTI around St. Lodge avenue, Pollards Hill, Helier Hospital in Merton. Mitcham, CR4 1LT For people with disabilities, it is widely acknowledged that familiarity and access, are two factors which may be compromised with proposed service changes, is a key part of treatment.

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An IHT equalities engagement highlighted that people with learning difficulties or mental health issues are likely to be disproportionately impacted as the lack of familiarity caused by a new hospital environment may adversely impact treatment. Sutton The Pavilion @ BedZED, 24 14:00 Those aged 65 Cheam There is evidence that older people (aged 65 and over) have a Sandmartin Way, – years old or older Sutton South disproportionate need for major acute services. Hackbridge, Wallington, 15.30 The highest density of those over 65 in the study area is found in the Surrey, SM6 7DF Wallington South Sutton CCG geography, with a density over 2000 per sq.km. Acute medicine admissions for older people are rising at twice the rate of demographic population growth, suggesting older people may be especially disadvantaged by planned service changes. An IHT equalities engagement highlighted a disproportionate impact of increased travel times, traffic, parking and public transport costs associated with planned service changes on elderly populations living in Sutton. Holy Trinity Church Centre, 20:15- People from a Sutton Central There is evidence that people from a BAME background have a Sutton, Cheam Road 21:45 BAME background St. Helier disproportionate need for major acute services, especially South Asian Sutton, Surrey, SM1 1DZ and African Caribbean demographics. Wandle Valley There is an especially high population of individuals from BAME backgrounds in Sutton (29%) compared to the UK average (20%) South Asian and African Caribbean are statistically more likely to have emergency admissions due to respiratory and cardiovascular disease then White British population, highlighting a disproportionate need. The Pavilion @ BedZED, 24 11:00 People from Wandle Valley There is evidence that people from deprived communities have a Sandmartin Way, – deprived St.Helier disproportionate need for major acute services. Hackbridge, Wallington, 12.30 communities Sutton central The highest levels of deprivation in the study area are found in Sutton Surrey, SM6 7DF with 5% of the population in most deprived quintile nationally. Deprived individuals are disproportionately impacted by increased travel costs associated with proposed service changes. This was cited as a major issue during an IHT equalities engagement. Holy Trinity Church Centre, 18:30- Females aged 18- Sutton Central By the very nature of the service areas under review, women who are Sutton, Cheam Road 20:00 44 Sutton South pregnant, new mothers, or breastfeeding will experience Sutton, Surrey, SM1 1DZ disproportionate need for this type of care - in 2016 85% of births in Wallington England were in an obstetric unit. North Surrey Bourne Hall, Spring Street, 18:30- Those aged 65 Stoneleigh There is evidence that older people (aged 65 and over) have a Downs Epsom, Surrey, KT17 1UF 20:00 years old or older Banstead disproportionate need for major acute services. Village Surrey Downs has a high population of adults 65 or older (20%) Ewell Court compared to Merton and Sutton.

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Population growth of this demographic in Surrey Downs is higher than in Merton and Sutton, suggesting this demographic may be disproportionately affected by planned service changes. An IHT equalities engagement highlighted a disproportionate impact of increased travel times, traffic, parking and public transport costs associated with planned service changes on elderly populations living in Surrey Downs. Bourne Hall, Spring Street, 20:15- Parents West Ewell By the very nature of these service areas, pregnant, new or Epsom, Surrey, KT17 1UF 21:45 Court breastfeeding mothers will experience disproportionate need for paediatric services and obstetric units. Molesey West There is a disproportionate use of A&E services by children aged 0-16, especially young children aged 0-4 who make up 10% of A&E admissions in England. Consequently, parents of children in this demographic may be disproportionately impacted by proposed changes to A&E services An IHT equalities analysis found a disproportionate impact of increased traffic, parking and public transport costs associated with planned service changes on parents. Epsom Playhouse, Ashley 20:15- Those aged 16- 24 Town There is evidence that younger people aged 16-24 have a Avenue, Epsom, Surrey, 21:45 years old Preston disproportionate need for major acute services. KT18 5AL Court Surrey Downs has a higher population of younger people aged 16-24 then Merton and Sutton (25,789), although all CCGs have the same proportion (9%) of 16-24-year olds. An IHT equalities engagement highlighted a disproportionate need in this demographic for specialist support for those with physical impairments and those with mental health issues. There is a disproportionate need for a specialist service to support young individuals with LLTI with a new acute service. This was cited as a major issue during an IHT equalities engagement. Epsom Playhouse, Ashley 18:30- People with a Molesey West There is evidence that people with LLTI have a disproportionate need Avenue, Epsom, Surrey, 20:00 Limiting Long-Term Preston for major acute services. KT18 5AL Illness (LLTI) Town Surrey Downs has the same proportion of LLTI sufferers as Merton and Sutton (14%), suggesting LLTI sufferers in all 3 CCG areas will be disproportionally affected by planned service changes. For people with disabilities, it is widely acknowledged that familiarity and access, two factors compromised by proposed service changes, is a key part of treatment. An IHT equalities engagement highlighted that increased journey times, parking and travel costs associated with planned service changes will have a disproportionate impact on those with mental

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health needs such as anxiety, agoraphobia and panic attacks; those with learning difficulties who travel alone and people with physical impairments who rely on patient transport and public transport. Source: Mott MacDonald

IHT Appendices to the Final Report 25 1 June 2020

Recruitment approach

Participants are being selected by an experienced market research agency and will be provided with an incentive to attend. The research agency will use a mix method approach to recruitment. Some participants will be recruited door-to-door and others via telephone. A number of the recruiters have databases that they may draw on to recruit from, carefully using the screener. All those who are recruited are then screened again by the office to confirm that they correctly qualify.

As mentioned, the recruiters will draw on a screening questionnaire to ensure participants represent the protected characteristics identified above. The screening document covers the following recruitment questions:

 Demographic questions – the recruiters will use these questions to ensure that they recruit individuals who meet the quota requirements for the groups (see below for more information on quotas)  Occupation industry exclusions – These questions are included to ensure that participants who take part do not work within certain industries. In particular: o Journalism and public relations – Those who work for these industries work within the public domain. To protect sensitive information about the programme and the views of those being expressed at the group from potentially being made public these groups are excluded.

o Market Research, advertising and marketing – Those who work in these industries are being screened out as they will likely be experience in market research processes and techniques. As such, they bring significant bias to the research; understanding how responses will be used and how to lead groups into discussions which fit their own agenda.

o CCGs, Epsom and St Helier and local authorities – Those who work for these organisations are likely to have previous involvement in the discussions around the future provision of acute services and therefore bring a degree of bias to discussions, they will also have opportunities elsewhere to provide their views. Further, to ensure that participants feel comfortable sharing their views and assured that these views will be reported anonymously, we are avoiding recruiting those who may be in a privileged position to share findings more widely outside of the formal written report.

 Previous attendance of focus group research – These questions have been included to exclude those who are considered as ‘professional participants’ from being recruited. These participants frequently contribute in market research, they often do not have an interest in the subject matter or may have previously engaged on the topic and as such their responses tend to be less authentic. These questions provide a useful proxy for ensuring that those who attend the groups are new voices, rather than those who have engaged in previous programme work.

 Comfortability with contributing to group conversations - Participants who are less comfortable talking in a group are more likely to be non-attenders on the day and are unlikely to contribute to such discussions. Those who answer that they are not comfortable speaking in groups conversations are therefore excluded. By asking this question, expectations are set around levels of contribution required and help to ensure individuals do not unwittingly agree to take part in something which they may find distressing. The recruiters have been provided with quotas on the characteristics they should recruit from and will be given postcode details for the three CCGs to ensure they only recruit participants

IHT Appendices to the Final Report 26 1 June 2020

who are resident within the appropriate CCG area which make up the defined study area. The table below shows the quota requirements for each group:

Table 2: Quota requirements CCG Group Composition Quota requirements number Merton 1 Females aged 18-44, from a  Please recruit 10 for 8 BAME background  All women  Mix of ages but at least one in each of the following ages bands:18-25, 26-35, 36-44  Mix of BAME groups but at least two who are from a black background and two from an Asian background. Merton 2 People from a BAME  Please recruit 10 for 8 background  Mix of gender  Mix of ages  Mix of BAME groups but at least two who are from a black background and two from an Asian background. Merton 3 People from deprived  Please recruit 10 for 8 communities  Mix of gender  Mix of ages Merton 4 People with a limiting long-  Please recruit 12 for 10 term Illness (LLTI) including  Only recruit those who identify as having a long-term disability illness  Mix of gender  Mix of ages Sutton 5 Those aged 65 years old or  Please recruit 10 for 8 older  Mix of gender  Only recruit those aged over 65 Sutton 6 People from a BAME  Please recruit 10 for 8 background  Mix of gender  Mix of ages  Mix of BAME groups but at least two who are from a black background and two from an Asian background. Sutton 7 People from deprived  Please recruit 10 for 8 communities  Mix of gender  Mix of ages Sutton 8 Females aged 18-44  Please recruit 10 for 8  All women  Mix of ages but at least one in each of the following ages bands:18-25, 26-35, 36-44 Surrey 9 Those aged 65 years old or  Please recruit 10 for 8 Downs older  Mix of gender  Only recruit those aged over 65 Surrey 10 Parents  Please recruit 10 for 8 Downs  Only recruit those with dependants aged under 18 at home  Mix of gender  Mix of age Surrey 11 Those aged 18-24 years old  Please recruit 12 for 10 Downs  Only recruit those between 18 and 24  Mix of gender Surrey 12 People with a limiting long-  Please recruit 12 for 10 Downs term illness including disability  Only recruit those who identify as having a long-term illness  Mix of gender  Mix of ages Source: Mott MacDonald

The following table outlines the wards which were targeted by recruiters for the deprived communities. Recruiters were provided with postcodes from within these wards which represented the LSOA areas in the highest quintile of deprivation for Merton and Sutton. Some of the wards listed below have areas which sit outside of the highest quintile of deprivation, through providing the specific postcode covering those LSOA areas in the top quintile, we sort

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to avoid recruiting anyone who was resident of one the areas outside of the highest quintile of deprivation.

Table 3: Wards for recruiting the deprivation groups CCG Ward Merton  Cricket Green  Figge's Marsh  Pollards Hill Sutton  Beddington South  Belmont  St Helier  Sutton Central  Wandle Valley Source: Mott MacDonald

Please note that Surrey Downs does not contain any wards in the highest quintile of deprivation.

The location of each focus group has been identified in conjunction with IHT. Where possible, preference has been applied to wards identified in the table 3 above. All venues have been checked to ensure that they are fully accessible and close to public transport links. Where paid for parking is the only option for participants, they will be able to claim this expense back from the team. Venues have been chosen with reference to the density maps for the characteristic group being recruited as a means to try and ensure that the venue is close to where those being recruited are likely to live.

Discussion guide

A discussion guide has been prepared by Mott MacDonald to help structure the conversations. This has been developed and was provided to the IIA Steering Group for review. Following discussion with the group, some of the language has been simplified and illustrative material added to support conversations. The guide has also been reviewed and assured by The Consultation Institute and has been signed off by the IHT Programme.

The guide will be used by moderators to assist them in their conversations. However, a degree of flexibility is allowed to moderators so that they can cover avenues of interest and ensure that discussions stay within time. Therefore, moderators are not limited to just the questions within the guide and are able to rephrase questions as they see appropriate.

B.1.4 Additional interviews with seldom heard groups In addition to the focus group, following discussion with the IIA steering group, Mott MacDonald is currently exploring the possibility of undertaking additional interviews targeted at additional equality groups. These groups have been identified as potentially having a disproportionate need for acute services but are likely to require a more flexible approach, beyond traditional focus groups, when engaging and gathering views.

In discussion with the IIA steering group, the following groups have been identified as requiring a more flexible approach to engagement:

 LGBT+  Carers  People with a learning disability  Gypsy, Roma, Traveller

IHT Appendices to the Final Report 28 1 June 2020

Mott MacDonald is currently speaking with relevant steering group members and key stakeholders to identify the most appropriate approach and forums to speaking with these groups. Steps are being taken to speak with these groups through the following methods:

 Joining existing meetings taking place and taking a short slot to discuss the most pertinent impacts felt to result from any of the options to change service provision  Working with membership organisations representing these groups to identify a number of individuals to have more focused one-to-one interviews  Arranging meetings with professionals working with these groups to hear about the experiences of their clients and the impacts as they see them from an expert standing. Discussions with relevant stakeholders is still ongoing and subject to change. Careful consideration will be given to ensuring a fair representation across the locality and to ensuring that a balance is achieved in terms of ensuring that these groups perspectives are heard but undue weight is not given to their views over and above other groups in the local community.

In addition, to the equality groups noted above it has also been flag in discussion with the steering group and key stakeholders that consideration should be given to engagement with Trust Staff. Mott MacDonald are currently exploring the potential to conduct a number of focus groups with staff, with the Programme and Trust.

B.1.5 Completion of groups The following has been appended to the note on 15 March following the completion of the initial focus groups.

The table below outlines the dates focus groups were undertaken and the attendance at each group. For each group, recruiters were requested to recruit for a minimum of eight people and a maximum of twelve. Please note that for the groups conducted on the 7 March with deprived communities and 4 March with those aged 65 years or older, recruiters experienced particular difficulties with these group including a number of last-minute drop outs. As such, only six and seven people respectively were in attendance on the night. Given that a number of participants in other groups were from postcode areas within the highest deprivation quintile in Merton and represented the 65 plus age group, it is currently felt that a mop up groups are not needed. However, it is recommended that Improving Healthcare Together seeks to further gather the views of this community when going out to public consultation.

CCG Location Time Date Composition Attendance at group Merton Colliers Wood Library, 18:30- 25.02.2019 Females aged 18- 8 Colliers Wood High St, 20:00 44, from a BAME London SW19 2HR background

Colliers Wood Library, 20:15- 25.02.2019 People from a 9 Colliers Wood High St, 21:45 BAME background London SW19 2HR Commonside community 18:30- 07.03.2019 People from 6 Development Trust: New 20:00 deprived Horizon centre, South Lodge communities avenue, Pollards Hill, Mitcham, CR4 1LT Commonside community 20:15- 07.03.2019 People with a 8 Development Trust: New 21:45 Limiting Long-Term Horizon centre, South Lodge Illness (LLTI) avenue, Pollards Hill, Mitcham, CR4 1LT

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Sutton The Pavilion @ BedZED, 24 14:00 14.03.2019 Those aged 65 10 Sandmartin Way, – years old or older Hackbridge, Wallington, 15.30 Surrey, SM6 7DF Holy Trinity Church Centre, 20:15- 12.03.2019 People from a 9 Sutton, Cheam Road Sutton, 21:45 BAME background Surrey, SM1 1DZ The Pavilion @ BedZED, 24 11:00 14.03.2019 People from 12 Sandmartin Way, – deprived Hackbridge, Wallington, 12.30 communities Surrey, SM6 7DF Holy Trinity Church Centre, 18:30- 12.03.2019 Females aged 18- 10 Sutton, Cheam Road Sutton, 20:00 44 Surrey, SM1 1DZ Surrey Bourne Hall, Spring Street, 18:30- 04.03.2019 Those aged 65 7 Downs Epsom, Surrey, KT17 1UF 20:00 years old or older Bourne Hall, Spring Street, 20:15- 04.03.2019 Parents 9 Epsom, Surrey, KT17 1UF 21:45 Epsom Playhouse, Ashley 20:15- 27.02.2019 Those aged 16- 24 11 Avenue, Epsom, Surrey, 21:45 years old KT18 5AL

Epsom Playhouse, Ashley 18:30- 27.02.2019 People with a 9 Avenue, Epsom, Surrey, 20:00 Limiting Long-Term KT18 5AL Illness (LLTI) Source: Mott MacDonald

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B.2 Screener questions for focus groups

Brook House

35a South Park Road

Wimbledon

plusfour market research limited London SW19 8RR

England

RECRUITMENT SCREENER

Participant Name:

Time of Group:

Date of Group:

Group no:

Hello, my name is [Recruiter]. We are carrying out a Market Research Survey about local health services and are looking for people to take part in a group discussion. I’d like to ask you some questions and, if you are eligible, invite you to participate. I need to let you know some information before we go any further. I am working on behalf of Plusfour Market Research Limited, an independent market research company. Plusfour have been commissioned by Mott MacDonald to recruit participants to take part in some research Mott MacDonald will be undertaking on behalf of Merton, Sutton and Surrey Downs Clinical Commissioning Groups. The answers that you give to me to today will be shared with Plusfour, as well as Mott MacDonald, this exercise is purely a research project to help our clients (Mott MacDonald and Merton, Sutton and Surrey Downs CCGs) to review local health services, so anything you say during the research exercise itself or during this interview will remain confidential. You can access Plus Four’s privacy notice on their website: www.plus4.co.uk/privacy You have the right to withdraw your consent to process the information you provide or object to our processing of your information. The research activity and this interview will be conducted in accordance with the Market Research Society Code of Conduct, and the information you provide will be treated in accordance with data protection law. This interview is just to establish eligibility for the research project and will take around 5 minutes. The research project itself will comprise a group discussion which will last around one hour and thirty minutes. As a token of our appreciation for participating eligible attendees will receive a cash thank you of £45 for their time. I just need to ask a few questions first to check your eligibility to take part.

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Are you happy to continue to see if you qualify?  Yes 1 Continue  No 2 Close

DEMOGRAPHICS

Q1. Code gender: RECORD, DO NOT ASK  Male 1  Female 2  Other 3  Prefer not to say 4

Q2. How old are you? WRITE IN AND CODE INTO THE RELEVANT BAND BELOW: ______

 18-24 1  25-34 2  35-44 3  45-54 4  55-64 5  65+ 6

Q3 Are you a parent or a legal guardian for any children aged under 16 living in your home?  Yes 1 (recruit for group 10 if in the relevant area)  No 2

Q4. Can you tell me which of the following best describes your ethnicity? White British:  White English / Welsh / Scottish / Northern Irish / British 1 Mixed / Multiple ethnic groups:  White and Black Caribbean 2  White and Black African 3  White and Asian 4  Any other Mixed / Multiple ethnic background – please specify: 5 Asian / Asian British:  Indian 6  Pakistani 7  Bangladeshi 8  Chinese 9

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 Any other Asian background - please specify: 10 Black / African / Caribbean / Black British:  Black African 11  Black Caribbean 12  Any other Black / African / Caribbean background - please specify: 13 Other ethnic group:  Non-British European - please specify: 14  Other - please specify: 15

Q5. Do you have any long-term physical or mental health conditions, disabilities or illnesses? By long-term, we mean anything lasting or expected to last 12 months or more. Please include issues related to old age.  Yes 1  No 2  Don’t know/can’t say 3  Would prefer not to say 4

Q6. Please tell me the area that you live in? WRITE IN - ______Postcode [ONLY RECRUIT THOSE FROM POSTCODES COVERING THE CCG AREA FOR THE GROUP. FOR THE DEPRIVATION GROUPS PLEASE ONLY RECRUIT FROM SPECIFIED POSTCODES] ______

OCCUPATION/INDUSTRY EXCLUSIONS

Q7. Are you:  Working full time (30+ hours per week) 1  Working part time (6-29 hours per week) 2  Working less than 6 hours 3  Education (GCSE or Pre-GCSE) 4  Education (A-level or equivalent) 5  Education (Vocational – write in) 6  Education (Degree or equivalent) 7  Education (Post-graduate) 8  Non-working 9  Retired 10  Other (write in) 11 Q8. Thinking about the following occupations, can you tell me which, if any: 1. You currently work in or have worked in the past?

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2. Any member of your family or close friend currently works in?

 Advertising (SCREEN OUT) 1  Market Research (SCREEN OUT) 2  Public Relations (SCREEN OUT) 3  Journalism (SCREEN OUT) 4  Marketing (SCREEN OUT) 5  NHS Surrey Downs, Sutton and Merton clinical commissioning groups (CCGs) (SCREEN OUT) 6  Epsom or St Helier University Hospitals NHS Trust (SCREEN OUT) 7  Local council/authorities (SCREEN OUT) 8  None of the above (CONTINUE) 9

PREVIOUS ATTENDANCE Q9. Are you scheduled to participate in a market research group discussion/depth interview in the near future?  Yes (SCREEN OUT) 1  No (CONTINUE) 2

Q10. Have you ever attended a market research discussion/depth interview?  Yes (ASK Q12) 1  No (GO TO Q14) 2

Q11. How long ago did you last attend a market research group discussion/depth interview?  In the last 6 months (SCREEN OUT) 1  6 months to 3 years ago (ASK Q15) 2  More than 3 years ago (ASK Q15) 3

Q12. How many market research group discussions/depth interviews have you attended in total?  IF MORE THAN 3 SCREEN OUT 1

WRITE IN: ______

Q13. Can you tell me which of the following statements best describes you?  I find it easy to talk within a group (CONTINUE) 1  I am happy talking to people I haven’t met (CONTINUE) 2  I sometimes feel intimidated by groups of strangers, and sometimes find I don’t know what to say (SCREEN OUT) 3  I sometimes feel uncomfortable in the company of new people (SCREEN OUT) 4

USE OF DATA

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Q14. It may be necessary for the Mott MacDonald to contact you by email or telephone after the research has taken place to follow up on ideas generated during the discussion. You would only be contacted if strictly necessary and only in connection with this research. Are you happy to agree to be re-contacted on this basis, and for us to pass your email address to the research team?

 Yes (Continue) 1  No (Refer to the office) 2

Recruiter Note: This question is to ensure that participants can be contacted directly in relation to this research. It does not permit re-contact of participants for any other purpose or panel building.

Any personal data you provide to us will be used only in relation to this project, will be securely stored and will be destroyed within six months of project completion. Your personal data will only be accessible by the following parties: Plus Four Market Research Limited and Mott MacDonald As part of our commitment to quality and in line with industry standards, Plus Four will recontact you to reconfirm you qualify, and to ask your experience of your recruiter and the recruitment process in general. The follow-up call takes only a couple of minutes. We will also send pre-group information/requirements to you by email and make a reminder call to you, up to 48 hours prior to the session. The host at the venue will register you on arrival, if you are late, they may call to check if you are lost/on your way. The moderator of the group will be from Mott MacDonald. We have contracts in place with any 3rd parties, governing how they can use the personal data (for specific research project only, for the purpose outlined above) and that they may not share them with other 3rd party organisations. Whilst Plus Four will retain your details for six months, other parties are required to securely destroy personal data immediately upon completion of the project.

Q15. Do you give consent to the use of your personal data for the purposes outlined above?

1. Yes CONTINUE 2. No – CLOSE

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INVITE TO PARTICIPATE IF THEY MEET ALL QUOTAS, HAS UNDERSTOOD THE PARTICIPANT INFORMATION SHEET AND HAS SIGNED THE CONSENT FORM

Q16. Do you have any special requirements we should make Mott MacDonald aware of in advance of the group, such as large print, easy read, sign language?  No 1  Yes (please write in) 2

RECRUITER: remind them that they will need reading glasses if applicable and need to arrive early, with ID. Please make sure you express how difficult non-attendance is for all concerned if not advised with sufficient notice.

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PARTCIPANT’S DETAILS (PLEASE COMPLETE IN BLOCK CAPITALS)

Title: Mr/ Mrs/ Miss/ Ms/ Other: ______

First name: ______

Surname: ______

We need the following information so we can send information about the project to you if necessary and for the office to contact you to confirm that you qualify for the research

EMAIL ADDRESS: ______@______

House Number/Name: ______

Street: Confirmation will be sent ______to you by your preferred ___ method:

Email 1 ______Post 2

Town/City: ______

Postcode: ______

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Telephone Number (Home):

______

Telephone Number (Work):

______

Mobile Number: - ______

CHECKLIST: PLEASE ENSURE YOU HAVE DONE INTERVIEWERS DECLARATION ALL OF THE FOLLOWING BEFORE CLOSING

Have you? This interview was conducted in accordance with the Market Research Code of Conduct. The (please tick once completed) participant is not a relative or friend of mine and was recruited:

Re-confirmed time and date - door-to-door 1 of group/depth? - telephone 2

Given venue details &

directions?

Interviewer’s name: Given Plus Four’s telephone

number 020 8254 4444?

Reconfirmed incentive Interviewer’s signature: amount? ______

Recorded mobile number & email address? Date: ______2019 (where applicable)

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Explained invitation & directions procedure?

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B.3 Focus group discussion guide Improving Healthcare Together: Integrated Impact Assessment Discussion guide

Objectives of the groups The objective of this focus group is as follows:  To gather views on the potential impacts of the options for change which have been identified as part of earlier work – where is there agreement and where does the group seek issue with the findings  To identify any gaps in evidence and any impacts which have not been considered by the work done to date – exploring gaps in terms of type of impacts, groups who may be affected and what these impacts may mean for local residents.

Materials required for the group Please ensure that you take following materials to every group:  Hard copy discussion guide for moderator and note takers  Sign in sheets (the host should bring this)  Participant details  Contact details for recruiter/host  Supporting material: o Animated video on memory stick and laptop o Protected characteristics handout o Further information handout o Engagement summary handout o Hospital location map o Example maps from travel analysis  Incentives and sign out sheet  Marker pens – Black red and green  Flip board paper  Post its  Paper for note taking etc

Overview of timings Each focus group is intended to be 90 minutes in length Each focus group intends to recruit between 10 to 12 individuals

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Time – Time – Time – group Time – group Item groups groups 7 5 1,3,8,9,12 2,4,6,10,11 18:15 – 18:30 20:00 – 20:15 10:45 – 11:00 13:45 – 14:00 Set up (15 mins) 18:30 – 18:40 20:15 – 20:25 11:00 – 11:10 14:00 – 14:10 Introduction (10 mins) 18:40 – 18:45 20:25 – 20:30 11:10 – 11:15 14:10 – 14:15 Warm up (5 mins) 18:45 – 18:55 20:30 – 20:40 11:15 – 11:25 14:15 – 14:25 Introduce proposals for change to services (10 mins) 18:55 -19:20 20:40 – 21:05 11:25 – 11:50 14:25 – 14:50 Discussion of impacts identified (25 mins) 19:20 – 19:30 21:05 – 21:15 11:50 – 12:00 14:50 – 15:00 Discrimination, harassment, victimisation and fostering good relations (10 mins) 19:30 – 19:45 21:15 - 21:30 12:00 – 12:15 15:00 – 15:15 Journey travel time (15 mins) 19:45 – 19:55 21:30 – 21:40 12:15 – 12:35 15:15 – 15:35 District services (10 mins) 19:55 – 20:00 21:40 - 21:45 12:35 - 12:30 15:35 - 15:30 Conclusion (5 mins)

Using the guide

QUESTIONS TIMING Bold = Key question or read-out statement: Questions that will be asked to Timings the participant if relevant. Not all questions are asked during fieldwork based on provided are a the interviewer’s view of progress. guide.  A bullet is a prompt: Prompts are not questions – they are there to provide guidance to the interviewer if required. CAPITALISED INSTRUCTIONS ARE TO THE INTERVIEWER Typically, the researcher will ask questions and use the prompts to guide where necessary. Not all questions or prompts will necessarily be used in an interview.

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The discussion guide

SECTION TITLE QUESTIONS OBJECTIVE TIMINGS

Introduction Hello and welcome to today’s focus group. My name is xxx and with me today is xxx. We both To set the scene, introduce 10 mins work for a company called Mott MacDonald. participants to the research, reassure about anonymity. We have been appointed by Improving Healthcare Together 2020-2030.

Improving Healthcare Together 2020-2030 is led by three Clinical Commission Groups (CCGs) - NHS Surrey Downs, Sutton and Merton CCG. These organisations are responsible for planning and paying for your local health services.

Improving Healthcare Together has been created to explore ways to address local health challenges, and make sure that NHS services can provide the best service for you in the future. In particular, it is focused on addressing three main challenges across Surrey, Sutton and Merton. These are:

 Improving the quality of health services  Providing healthcare services in modern buildings  Achieving financial sustainability We, Mott MacDonald, have been asked to independently undertake what is known as an ‘integrated impact assessment’, or IIA, to look at a number of potential changes Improving Healthcare Together is considering making to health services in your local area.

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An integrated impact assessment purpose is to explores the potential impacts of a proposed change, focusing on the impact the change may have on the local community. This includes highlighting both positive impacts and negative impacts that might occur for different groups in the community.

In doing the IIA we hope to help Improving Healthcare Together to think through the consequences of any changes they may make to the way health services are provided in your local area.

The Integrated Impact Assessment looks at impacts across four areas. These include: 1. Equality impacts –the impacts of the changes on different groups of people in the local community. This covers age, disability, gender reassignment, marriage and civil

IHT Appendices to the Final Report 43 1 June 2020

partnership, race, religion or belief, sex, sexual orientation – that’s our focus today - please see handout! 2. Health impacts – this assesses the impacts of the changes on local health outcomes and your healthcare system 3. Travel and Access impact– this explores the impact the change may have on how long it takes to travel to access health services and how easy it is to access these services 4. Sustainability impacts – this looks at if the impact will affect pollution in the area such how will it impact on local air quality and carbon emissions.

The final report we produce for this work will look at the impacts across all the areas we are exploring and will highlight how they are linked to each other.

Today we would like to discuss some of the impacts we have identified with you and hear your views on these and where you think we have missed potential impacts. So, we will tell you more about the proposed changes and your discussion will help to inform our assessment. In particular, we would like you to think about the different equality groups I mentioned earlier and how experience in the community may vary.

To be clear we are independent from the three CCGs who have asked us to do this work and have no involvement in the suggested changes they are reviewing. So please feel you can be open and honest with us.

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For those of you who have not been part of a focus group before, it is simply an informal group discussion. There are however a number of ground rules we would like to establish with you before we start.

Ground rules:  Respect for each other: I would like to ask everyone to be respectful of others in the group, especially if someone chooses to share something that is personal. We don’t want anyone to feel uncomfortable because of what other people are saying.  Everyone gets a chance to speak: If you’re someone who likes to talk a lot, that’s great, but make sure you give everyone else chance to speak; likewise, if you usually sit back and listen to others, we really want to hear what you think as well! Please try and avoid speaking over each other to help our notetaker!  No right or wrong answers: If you disagree with what someone else says, that’s fine – we want to hear everyone’s views! There are no right or wrong answers to the questions we ask, we are interested to hear about what you think. Be conscious about how much or how little you’re saying in the discussion.  Reporting: We’ll be writing up what we find out from this group and using the feedback to form the basis of our report. We won’t identify sensitive information or use names. We might use some quotes of things participants have said, but there will be no names attached to them and no one in this room will be named as having attended the group.  Recording: I would like to record the focus group – this will be to help me write up my notes and report. Please let me know if you have any concerns with this.

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Housekeeping 5. Group will last about an hour and half 6. Phones off 7. Toilets 8. Fire alarm – not expecting a drill

Participants to introduce themselves 9. First name

10. If they have visited someone in hospital or used hospital services in the last five years. Don’t need to tell us why you went we are just interested in knowing who has a recent experience. It’s fine if you haven’t been.

USING HEALTHCARE SERVICES

Warm up To start, can you share with us the first two or three words that come into your head To help ease participants into 5 mins when you think about using health services – for example going to the hospital or GP? the questions and to also get them thinking about what is [FLIPCHART] important to them when PROBE: accessing health services. • Why do you say that?

What makes your experience of using health service positive? PROBE:

 Why do you say that?

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And what makes it less positive? PROBE:

 Why do you say that?

PROPOSALS FOR CHANGE

Introduce So, we have thought about what is most important to you when using healthcare This section introduces the 10 mins proposals for services, I would like to show you a short video which has been prepared by Improving proposals to the participants change to Healthcare Together and explains what changes to your local health services they are and gives them an services considering and why. opportunity to ask questions [PLAY VIDEO – ONCE VIDEO HAS FINISHED HANDOUT SUMMARY - MODERATOR NOTE THAT THE HANDOUT IS A REFERENCE TOOL FOR PARTICIPANTS TO REFER BACK TO THROUGHOUT THE DISCUSSION] To summarise, while district services in Epsom and St Helier hospitals will remain largely unchanged, Improving Healthcare Together is considering how major acute services are best delivered in your local area. The major acute services they are looking at covers: 11. A&E - An A&E department (also known as emergency department or casualty) deals with genuine life-threatening emergencies. 12. Acute medicine – Acute medicine deals with adult patients with a wide range of medical conditions who present in hospital as emergencies. 13. Emergency general surgery – Emergency surgery deals with, among other things, operations for patients (adult and paediatric) admitted through the emergency department during the out-of-hours period

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14. Obstetrics – Obstetrics deals with medicine and surgery concerned with childbirth and midwifery. 15. Paediatrics - Paediatrics deals with conditions affecting infants, children and young people. 16. Intensive care – Intensive care is the specialist treatment and monitoring for people who are seriously ill. Intensive care units are also sometimes called critical care units (CCUs) or intensive therapy units (ITUs).

The three options they are considering in terms of how these services are delivered are: 17. Locating major acute services at Epsom Hospital, and continuing to provide all district services at both Epsom and St. Helier 18. Locating major acute services at St. Helier Hospital, and continuing to provide all district hospital services at both Epson and St. Helier 19. Locating major acute services at Sutton Hospital, and continuing to provide all district services at both Epsom and St. Helier

INTERVIEWER- REFER TO THE SLIDE DECK AND THE THREE AIMS OF THE IHT _ EXPLAIN HOW OPTIONS MAY ACHIEVE THIS. Does anyone have any questions about the proposals?

Discussion of Improving healthcare together has already undertaken some engagement with the local This section is aimed at 25 mins impacts identified community to understand their views on these proposed changes. These discussions understanding the level of have highlighted a number of potential positive and negative impacts. I would like to agreement for impacts which share these with you to hear your thoughts. have already been identified.

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[PROVIDE GROUP WITH HANDOUT AND MAP OF HOSPITAL LOCATIONS] It is also looking to explore any potential gaps in the With your neighbour I want you to spend ten minutes looking at these impacts. Please impacts which have been think about what they mean to you and others like you. Do you agree with them? Is there identified anything missing? In your discussion, please consider how, for you, these impacts differ if at all depending on which of the three site options were selected [Epsom or St Helier or Sutton].

[MODERATOR GIVE THE GROUP 5 MINUTES TO DISCUSS WITH THEIR PARTNER AND THEN RETURN BACK TO A GROUP DISCUSSION] So, you have had a chance to discuss with your partner, so starting with the positive impacts which have been identified. What did people think about these? Did you agree with them? PROBES

 Moderator to probe protected characteristics  Why / why not?

Are there any positive impacts that you and your partner felt have not yet been identified which are relevant to you and others like you? [FLIPCHART – PLEASE RECORD FEEDBACK ON IMPACTS BY SITE] PROBES:

 Moderator to probe protected characteristics and any other groups who may be impacted.

Looking back over the positive impacts which have been identified, is there anything that can be done to increase their benefit for the local community?

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[MODERATOR REPEAT QUESTIONS FOR NEGATIVE IMPACTS]

And what about the negative impacts, what if anything, could be done to minimise these impacts? PROBE: • Why do you say that? How realistic is this? PROBES POSITIVE IMPACTS: Quality of care received by patients, continuity of care for

patients, experience of care for patients, convenience and access to care for patients and their

families/friends, availability of beds, servicing population growth, waiting times, accessing a

centre of excellence, increased demand for ambulance services.

PROBES NEGATIVE IMPACTS AND MITIGATIONS: specialist support for certain groups,

convenience and access to care for patients and their families/friends, cultural sensitivities

(food/language), reassurance around the quality and continuity of care for patients, availability

of beds, dealing with population growth, waiting times, demand for ambulance services

Discrimination, We have spoken about the impacts, but I want to spend a few minutes looking very MODERATOR NOTE THAT 10 mins harassment, specifically at your views on the fairness of these proposals for change and their impact YOU MAY HAVE COVERED victimisation and on local equality. SOME OF THIS PREVIOUS fostering good SECTIONS BUT WE NEED

relations TO ENSURE THAT WE COVER ALL THE

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MODERATOR MAKE SURE FOR ALL QUESTIONS BELOW YOU PROBE ON WHAT THE QUESTIONS IN THIS PROGRAMME COULD DO TO ADDRESS THESE. SECTION IN SOMEWAY TO MEET THE EQUALITY

DUTY. Is there anything about these proposals which is unfair, puts you at a disadvantage

compared to others or which you feel discriminates against you? These questions have been PROBE: added to address Section  Are other equality groups in the community disadvantaged or discriminated against 149 and Section 14T of the because of these proposals? Equalities Act 2010  Is there anything about these proposals which would reduce the quality of care you would receive or lead to worse health outcomes?

Moderators, it is important Is there anything about these proposals which may fail to meet your needs or the needs that all these questions are of others like you? covered with the group and all responses are recorded. PROBE:

 Are there any other groups whose needs you feel they may fail to meet?

Is there anything about these proposals which favours some groups in the community more than others, and gives them an unfair advantage? PROBE:

 Could this create bad relations or issues between different groups in the community? FOR EXAMPLE:

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Some equality groups or people in the community might feel that spending money and investment on providing more access and facilities for disabled people is dis-proportionate and not justified.

Are there any groups who you feel should be treated differently or more favourably to ensure the new service provision is adequate and fair for all?

Journey travel Our team have done some work to understand how moving acute services on to one The aim of this section is to 15 mins time hospital site only could impact on journey times to access acute services for the local gauge response to the travel community. We have looked at this for each option. analysis and qualitatively understand what the

changes in time may mean [MODERATOR HAND OUT EXAMPLE – EXPLAIN WHAT THE EXAMPLE SHOWS] for the participants.

What do you think will be the impact of these change in journey times? MODERATOR PROMPT ON – transport, accessibility, longer journey times, limited parking,

parking costs and increased travel costs

PROBE: • How, if at all, will it affect you/others? • Would any of the impacts affect you more than other people? Why? • What about disabled people, is there anything about any of the options which could make access to services more difficult for people with disabilities? Which sort of disabilities and how? • What could be done to increase benefits or reduce any negative impacts?

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District services Finally, before we wrap up today I just want to spend 5 minutes discussing district services. So, These questions seek to 10 mins you may remember in the video that while major acute services may be moving district services better understand what will continue to be located in all hospital sites. If you look at the hand out in the beginning, you impact district level service can see what these district services cover. changes may have. [MODERATOR SPEAK THROUGH THE DISTRICT SERVICES]. As part of the programme of change some of these services will be enhances/ made better, for MODERATOR PLEASE example, urgent care treatment centres will be expanded so they can better detail with urgent MAKE SURE YOU HAVE A cases which come in, to reduce the need for people to go to A&E. They are also considering CLEAR IDEA OF WHAT developing one stop clinics, where a patient could have their consultation and diagnostic test DISTRICT SERVICES ARE as part of the same appointment rather than having to attend different sites at different times AND THE PROPOSED and virtual / tele triage and follow up appointments. CHANGES. What impact do you think this will have on you? PROBE: • Others? • What do you think about these changes being made alongside the changes to acute services? Conclusion I would like to finish by asking a quick summary question To wrap up the discussion 5 mins Thinking about everything we have discussed today, what do you see as being the main positive impact that the potential changes to major acute service could bring for you and those like you? And what is your biggest concern about any change to major acute service you and those like you? MODERATOR: GO AROUND EACH PERSON IN THE GROUP.

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Is there anything else you would like to mention today, that we have not already covered about the proposed changes?

THANK AND CLOSE.

MODERATOR AND NOTETAKE TO HAND OUT INCENTIVES AND INCENTIVE SIGNOUT SHEET.

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B.4 Note on focus group recruitment Improving Healthcare Together 2020 – 2030 – Integrated Impact Assessment

Focus group recruitment

The location of each focus group has been identified in conjunction with IHT. Focus groups were designed for between 8-12 participants at each; allowing each participant to contribute to the discussion. Venues were chosen with reference to population density maps for each protected characteristic to try and ensure that they were run close to where those being recruited were likely to live. All venues were checked to ensure that they were fully accessible and close to public transport links.

Given the study area covers the combined geography of the three CCGs, four groups were run in each CCG area. As much as possible the protected characteristic groups chosen to be interviewed in each CCG area where chosen on the basis of where highest densities were located. The recruiters were provided with quotas on the characteristics they should recruit from within each CCG and were given postcode details for the three CCGs to ensure they only recruited participants who were resident within the appropriate CCG area. The only variation to this approach was in relation to the deprivation focus groups where recruiters were required to recruit from specific postcodes within the CCG area which covered the highest quintile of deprivation.

The table below outlines the wards represented at each focus group across the participants:

Group Postcode Number CCG Venue Composition Wards covered number eligibility in group

Colliers Wood Abby = 1 Library, Females aged Colliers Wood = 2 Colliers Wood 18-44, from a Merton Longthornton = 1 Merton 1 8 High St, BAME postcodes St Helier = 1

London SW19 background Wimbledon Park = 2 2HR Figge's Marsh = 1

West Barnes = 1 Colliers Wood Pollards Hill = 2 Library, Longthornton = 1 People from a Colliers Wood Merton Lavender Fields = 1 Merton 2 BAME 9 High St, postcodes Abbey = 1 background London SW19 Trinity = 1 2HR St Helier = 1 Figge's March = 1

Commonside Merton community People from postcodes Pollards Hill = 4 Merton 3 Development deprived from the 6 Cricket Green = 2 Trust: New communities most Horizon deprived centre, South IMD quintile

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Group Postcode Number CCG Venue Composition Wards covered number eligibility in group

Lodge (this will be avenue, supplied Pollards Hill, separately). Mitcham, CR4 1LT

Commonside community Development People with a Cricket Green = 1 Trust: New limiting long- Raynes Park = 1 Horizon term Illness Merton Abby = 1 Merton 4 centre, South 8 (LLTI) postcodes Dundonald = 2 Lodge including Lower Morden = 2 avenue, disability Merton Park = 1 Pollards Hill, Mitcham, CR4 1LT

The Pavilion @ BedZED, The Wrythe = 4 24 Wallington South = 1 Sandmartin Those aged 65 Sutton Wandle Valley = 1 Sutton 5 Way, years old or 10 postcodes Cheam = 1 Hackbridge, older Nonsuch = 2 Wallington, Worcester Park = 1 Surrey, SM6 7DF

Holy Trinity Carshalton South and Church Clockhouse = 1 Centre, Nonsuch = 1 People from a Sutton, Sutton The Wrythe = 1 Sutton 6 BAME 9 Cheam Road postcodes Wallington North = 1 background Sutton, Wallington South = 1 Surrey, SM1 Wandle Valley = 2 1DZ Worcester Park = 2

The Pavilion Sutton @ BedZED, postcodes 24 from the Sandmartin People from most Wandle valley = 7 Sutton 7 Way, deprived deprived 12 St Helier = 1 Hackbridge, communities IMD quintile Beddington South = 4 Wallington, (this will be Surrey, SM6 supplied 7DF separately).

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Group Postcode Number CCG Venue Composition Wards covered number eligibility in group

Holy Trinity Church Beddington South =1 Centre, Carshalton Central =1 Sutton, Females aged Sutton Sutton 8 10 Sutton West = 3 Cheam Road 18-44 postcodes The Wrythe = 4 Sutton, Worcester Park = 1 Surrey, SM1 1DZ

Brockham, Betchworth and Buckland = 1 Bourne Hall, Cobham and Downside= 1 Spring Street, Those aged 65 Surrey Surrey Esher= 1 9 Epsom, years old or Downs 7 Downs Ewell Court= 1 Surrey, KT17 older postcodes Molesey East= 1 1UF Stoneleigh= 1 Tattenhams= 1

Bookham South =1 Court = 1 Dorking North = 1 Bourne Hall, Kingswood with Burgh Heath = Spring Street, Surrey Surrey 1 10 Epsom, Parents Downs 9 Downs Leatherhead South = 1 Surrey, KT17 postcodes Molesey West = 1 1UF Stamford = 1 Tadworth and Walton = 1 Thames Ditton = 1

Stoneleigh = 2 Epsom West Ewell = 2 Playhouse, Town = 2 Ashley Those aged Surrey Leatherhead north = 1 Surrey 11 Avenue, 18-24 years Downs 11 Kingswood with Burgh Heath = Downs Epsom, old postcodes 1 Surrey, KT18 Stamford = 1 5AL Woodcote=1 Ashtead village = 1

Fetcham East = 1 Epsom People with a Capel, Leigh and Newdigate=1 limiting long- Surrey Surrey Playhouse, Beare Green = 1 12 term illness Downs 9 Downs Ashley Banstead Village = 1 Avenue, including postcodes Leatherhead North = 1 Epsom, disability Nork= 1 Auriol = 1

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Group Postcode Number CCG Venue Composition Wards covered number eligibility in group

Surrey, KT18 Ashtead Park = 1 5AL Oxshott and Stoke D'Abernon = 1

CCG Ward Merton  Cricket Green  Figge's Marsh  Pollards Hill Sutton  Beddington South  Belmont  St Helier  Sutton Central  Wandle Valley

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B.5 Delivery of additional engagement Following feedback from both the IIA Steering Group (see B.1.4) and the local authority Joint Health Overview Scrutiny Committee a series of additional engagement was attempted. Details on steps taken and outcome are outlined below:

B.5.1 Staff focus groups: Working with the Epsom and St Helier University Hospitals NHS Trust an email was sent to all staff within the Trust inviting them to one of two focus groups being held at Epsom and St Helier hospitals respectively.

The first focus group was held in St Helier on 13 June 2019 and was attended by 16 members of staff. The second focus group was conducted on 27 June 2019 and was attended by eight members of staff. Across the groups a range of staff were represented including healthcare professionals, back room/administration staff and service delivery staff.

The focus groups were run over lunch time to better enable staff attendance and discussion guide was used to focus conversation. The guide covered similar material to that in the equality group engagement but was tailored to staff. Key discussion areas covered:

1 Current experience of working for the Trust

2 Initial thoughts on the options for change

3 Views on positive impacts for staff

4 Views on negative impacts for staff

5 Impact on staff with protected characteristics

6 Mitigation and enhancement action

7 Views on the impact of change on patients

8 Consideration of the changes to district services and impact

B.5.2 Additional Deprivation focus group An additional focus group with people from the two highest quintiles of deprivation in Merton, was undertaken on 26 June 2019. This was done to ensure that the views of those from more deprived areas in Merton who currently use services at St Helier were given consideration. The recruitment for these groups was focused on people who lived in postcodes areas within the top two quintiles of deprivation and focus on the wards of Ravensbury and St Helier (closest to the St Helier hospital site).

As with the focus groups previously undertaken with equality groups, recruitment for this group was undertaken via and external recruitment agency. The focus group started at 6:30pm to allow adequate time for those working to attend and was undertaken St Teresa Church Hall in Morden. The group was attended by 10 local residents: 6 were from the St Helier ward and 4 were from Ravensbury ward. Conversations were guided by the same discussion guide used in all the equality focus groups (see B.3).

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B.5.3 Engagement with carers and people with a learning disability Following discussion with the IIA Steering Group, Mott MacDonald was asked to seek the views of those with a learning disability and carers. It was felt by the steering group that the experience these groups should be given special consideration. Using contact leads provided by the steering group, Mott MacDonald made contact with a range of organisations to seek support in gaining access to carers and people with a learning disability. With aid from the team at Mid Surrey Valuing People Group, Mott MacDonald was able to attend their monthly meeting and run a focus group with the attendees which included people with a learning disability, carers of people with a learning disability and professionals providing support and advocacy for those with a learning disability. Roughly 20 people attended of which around a third had a learning disability. The conversation was structured using the same discussion guide as all equality focus groups (see B.3) but tailored to the needs of those with a learning disability.

Contact was also made with a number of local organisation representing carers beyond those with a caring responsibility for people with a learning disability. However, unfortunately these organisations did not respond to the request for support. Mott MacDonald therefore recommends that the Programme seeks to begin early conversations with these organisations to ensure that the views of carers are adequately reflected in the public consultation through their engagement activities. Any findings coming out of the public consultation relating to the experience of carers will be reflected on in the final version of the IIA report.

B.5.4 Engagement with the LGBT+ community and Gypsy, Roma, Traveller Community In addition, to carers and people with a learning disability, Mott MacDonald also attempted to gather the views of the local LGBT+ community and Gypsy, Roma, Traveller community. Mott MacDonald contacted a range of organisations representing the LGBT+ community in the local area. Contact was made with the Merton LGBTQ+ forum and an expert interview undertaken with a member of the team. The forum also posted an advertisement to take part in a focus group on their website but unfortunately did not receive a response. Mott MacDonald also contacted a number of local authority teams working with the Gypsy, Roma and Traveller community as well as local members of the community. Mott MacDonald have not been able to convene a focus group, but discussion is ongoing, and the Programme will be picking up on these leads for public consultation. Again, Mott MacDonald recommends that the Programme, seeks to begin early conversations with representatives of these groups to encourage their engagement as part of the public consultation process. Any findings coming out of the public consultation relating the experience of these groups will be reflected on in the final version of the IIA report.

B.6 Solutions workshop Scope and objectives of the workshop

On 8th April 2019 a Solutions workshop was undertaken with a range of stakeholders with an interested in local transport provision and/or access issues for local community groups.

The objectives of the workshop were to:

• Share early findings from the travel and access analysis with stakeholders

• Explore potential mitigation action in relation to travel impacts identified. In particular seek to:

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o understand any future plans around travel and access across the study area which may support easier access to the three hospital sites;

o understand where and what action stakeholders felt could be taken to support better travel and access to and between the three hospital sites; and

o test whether stakeholders agreed with the actions that had been identified as needing to be taken to support better access to the three hospital sites.

Attendance

The following representatives attending the workshop:

Organisation Number of representatives Family Voice Surrey 1 Surrey County Council 2 Sight for Surrey 1 East Surrey Transport Committee 1 Merton Council 1 London Ambulance Service NHS Trust 1 Surrey Downs CCG 1 Merton Community Transport 1 Merton CCG 4 Action for Carers 1 Mary Frances Trust 1 Carers Support Merton 1 Age UK, Merton 1 Mole Valley Life, Mole Valley District Council 1 Sutton CCG 2 Epsom and St Helier University Hospitals NHS Trust 1 Evolve Housing 1 Sutton Council 2 South East Coast Ambulance 1 Morden Mosque 1 Commonside Trust 1 Mott Macdonald 3 IHT Programme Team 6

Format of the day

The format of the day has been outlined in the table below:

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Timings Session Lead Facilitator instructions

Facilitators arrive and set up room Snacks and drinks placed on side table

8:30 – 9:15am Room and materials set up (45 mins) MM and IHT 6 Round tables set up Sheets and maps placed around the room Make sure the video and presentation are working Quick team briefing  Greet participants and provide them with a name badge Teas and coffee – meet and greet (15 9:15 – 9:30am All  Direct to teas and coffee mins)  Invite them to be sat at a table by 9:30am – they can sit at any table

Welcome and brief introduction to the 1. Welcome and thank participants for coming 9:30 – 9:40am Programme and options for change (10 IHT (AD) 2. Explain the programme and options min)

 Introduce the work MM are doing and the purpose of the day  Invite participants to introduce themselves and the organisation they represent Introduction to the IIA and purpose of the 9:40 – 9:50am MM (BN) workshop (10 mins)  Outline that high-level questions can be asked throughout the day but flag that more detailed questions can be outlined on questions sheet and addressed, if time, at the end (if no time available MM can send a response round), also highlight FAQ document on table  Outline the findings of the travel analysis Overview of the travel and access data 9:50 – 10:10am MM (CW) Mention that if interested in seeing more of the maps MM will be able to go and any high-level questions (20 min)  through these at the end of the session with individuals

10:10 – 10:30am Findings of the focus groups (20 mins) MM (HF)  Outline the findings of the focus groups and introduce initial mitigations

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 Explain that having a 10 min rest break before the interactive session begins 10:30 – 10:40am Rest break (10 mins) MM (HF)  All facilitators to encourage group to be back in their seats before 10:40am  Explain the sheet exercise and outline that any mitigation action they think of which is not linked to an impact area but which they feel is important to be outlined on additional impact sheet MM and IHT  5 mins a sheet – will be encouraged to move on after 5 mins (BN to 10:40 – 11:30am Sheet exercise (50 mins) introduce the  Split group into 9 smaller groups each starting on a different sheet task)  Clockwise rotation  Facilitators allocated to stand next to a sheet – encourage conversation and take notes where possible  Bring the room back together  Each facilitator to briefly outline the key themes on their sheet – state MM and IHT anything you think was particularly interesting (BN and HF to  Depending on numbers on the day, may need to split room into two 11:30 am – 12:10 noon Group discussion (40 mins) lead) subgroups  Ask the group(s) to reflect on the findings – use the questions on the slides – flip chart responses  If time and if any identified, explore the additional mitigations  Open floor for final comments

12:10 – 12:20 noon Closing discussion/Next steps (10 mins) MM (BN)  If time answer any questions on the question sheet  Thank everyone for taking part  Before participants leave, give each participant three stickers and ask them to 12:20 – 12:30 noon Ranking exercise (10 mins) MM (HF) put a sticker next to the three mitigation/solution actions they feel should be the priority.

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C. Air Quality Assessment Methodology

A qualitative assessment of air quality impacts has been made using publicly available information on existing pollutant concentrations and the predicted changes in patient numbers as a result of the proposals. The objective of the assessment is to provide a qualitative description of potential impacts and enable a comparison between different options. A quantitative assessment of changes in pollutant concentrations due to the proposals will be undertaken at a later stage, as more detailed information becomes available.

For the baseline review, data was obtained from:

the London Atmospheric Emissions Inventory (LAEI) 2013; automatic and non-automatic monitoring data from the London Borough of Sutton and Epsom and Ewell Borough; and the DEFRA Pollution Climate Mapping (PCM) model. Existing concentrations can determine the ability of receptors to absorb changes in air quality, therefore baseline air quality data has been used to assign the sensitivity of receptors in the area around each hospital as in Table 4 below:

Table 4: Sensitivity criteria for air quality assessment Sensitivity Description Low Baseline air quality in the surrounding area is well below the air quality objectives and EU limit values Medium Baseline air quality in the surrounding area is just below the air quality objectives and EU limit values High Baseline air quality in the surrounding area is above the air quality objectives and EU limit values

The air quality objectives and EU limit values are concentration-based thresholds to protect public health, and public authorities and the Government are required to take action when these are exceeded. Their numerical values, and the number of permitted times in a year concentrations can pass the numerical values are provided in Table 5 below:

Table 5: Air Quality Objectives and Limit Values Attainment Date Averaging Pollutant Concentration Allowance Air Quality Period EU Limit Values Objectives 31 December Annual 40 μg/m3 - 1 January 2010(c) Nitrogen 2005(a) dioxide 18 hours per 31 December (NO2) 1 Hour 200 μg/m3 1 January 2010(c) year 2005(a)

3 31 December (c) Annual 40 μg/m - (a) 1 January 2005 Particulates 2004 (PM10) 35 days per 31 December 24 Hour 50 μg/m3 1 January 2005(c) year 2004(a) Fine particulates Annual 25 µg/m3 - 2020(b) 2015(c)

(PM2.5) Notes: An objective is considered exceeded if the pollutant concentration averaged over the relevant period is higher than the stated value. For short-term objectives (hourly for nitrogen dioxide, daily for particulates) a certain number of periods above the stated value in a calendar year is allowed before the objective is exceeded. (a) Air Quality (England) Regulations 2000 as amended in 2002

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(b) Air Quality Strategy 2007 (c) EU Directive 2008/50/EEC on ambient air quality and cleaner air for Europe and The Air Quality Standards Regulations 2010. Derogations (time extensions) have been agreed by the EU for meeting the NO2 limit values in some zones/agglomerations; The magnitude of change from the proposals has been determined based on the change in patient visits per day at each hospital compared to the ‘do-minimum’ situation in 2025/2026 (baseline). The magnitudes are described in Table 6 below:

Table 6: Magnitudes for air quality assessment Magnitude Description Negligible Patient visits per day change by less than 50 Low Patient visits per day change by between 50 and 100 Medium Patient visits per day change by between 100 and 250 High Patient visits per day change by more than 250

The projected duration of impacts has also been categorised as detailed in Table 7 below:

Table 7: Duration of impacts for air quality assessment Duration Description Low Short term (under one month) Medium Medium term (under one year) High Long term (over one year)

A summary of baseline concentrations around each hospital is provided in Table 8. This shows that pollutant concentrations vary across the city and around each hospital. Concentrations measured at the nearest monitoring station are reported, which might not be fully representative of concentrations at the hospital or at the nearest receptors with worst-case exposure to poor air quality. The qualitative assessment of sensitivity for each location took into account both monitored concentrations for 2017 and predictions from the LAEI for the year 2020.

Table 9 presents the changes in patient visits per day at each of the hospitals for each of the scenarios.

Table 10 presents the results of the assessment for each of three scenarios

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Table 8: Baseline air quality at sensitive locations considered in the assessment

Sensitive Located In or near an Nearest NO2 Nearest PM LAEI predicted Worst-case LAEI predicted Sensitivity location within AQFA? non- automatic concentration relevant concentration an automatic monitoring in 2020 at exposure in 2020 at worst AQMA? monitoring data for 2017 hospital case exposure data for 2017 location location

3 3 Epsom No No EE49 37 South ST6 Worcester NO2 = 23µg/m Residential NO2 = 30µg/m Low 3 3 Hospital Street (760m) – Park (6.3km) PM10 = 22µg/m properties at PM10 = 23µg/m 3 29µg/m (well 3 3 junction A24 3 PM10 = 20µg/m PM2.5 = 13µg/m PM2.5 = 14µg/m below the (well below the Dorking annual NO2 Road/Ashley annual PM10 objective) objective) Avenue 3 3 St Helier Yes No ST39 Rose Hill ST5 Beddington NO2 = 28µg/m Residential NO2 = 38µg/m Medium 3 3 Hospital (Sutton Roundabout Lane (north) PM10 = 23µg/m properties on PM10 = 25µg/m AQMA) (620m) – (3.1km) 3 B278 Wrythe 3 PM2.5 = 14µg/m PM2.5 = 15µg/m 3 3 39µg/m (just PM10 = 31µg/m Lane close to below the 3 Rose Hill PM2.5 = 15µg/m annual NO2 Roundabout objective) (well below the objectives) 3 3 Sutton Yes 1.3 km south of ST22 Dorset ST4 Wallington NO2 = 24µg/m Flats on A232 NO2 = 36µg/m Medium 3 3 Hospital (Sutton Sutton A232 Road, Belmont (3.3km) PM10 = 22µg/m (Sutton AQFA) PM10 = 25µg/m 3 AQMA) Cheam/Carshalton (840m) – PM10 = 25µg/m 3 and on 3 3 PM2.5 = 14µg/m PM2.5 = 15µg/m Rd/High St/Brighton 39µg/m (just (well below the Brighton Road Rd AQFA below the annual PM annual NO 10 2 objective) objective) Source: LAEI 2013, London Borough of Sutton, London Borough of Sutton and Epsom and Ewell Borough.

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Table 9: Change in attendance numbers in 2025/2026 (patients per day) Scenario Epsom St Helier Sutton St Peter’s Kingston Royal Surrey East Surrey St George’s Croydon Hospital Hospital Hospital Hospital Hospital Hospital Hospital Hospital University Hospital Major acute 73.3 -202.5 0.0 0.3 6.9 -0.4 -0.3 68.7 53.9 services at Epsom Major acute services at St -155.1 77.4 0.0 28.6 25.4 6.9 13.0 1.1 2.8 Helier Major acute -155.1 -202.5 316.5 18.3 11.4 6.3 6.1 12.9 -13.9 services at Sutton Source: Improving Healthcare Together 2020-2030. Finance, activity and estates group – draft for discussion

Table 10: Air quality impacts by scenario and sensitive location Scenario Area Subtopic Description of Impact Receptors Direction Sensitivity Magnitude Duration Impact (Positive, High (H), Major (H), Long (H), neutral, medium (M), moderate medium negative) low (L) (M), minor (M), short (L), (L) negligible (N)

Acute Sustainability Epsom Worsening of air quality (NO2, Patients, local Negative L - Baseline air L – Patient H - long Services at Hospital PM10 and PM2.5) as a result of residents and any quality in the visits per day term (over Epsom a small increase in the number other vulnerable surrounding increase by one year) of patients attending this groups (i.e. area is well between 50 Hospital (due to increase in schools, care below the air and 100 major acute service provision) homes) located on quality and travelling by private car or the main access objectives and ambulance on A24 Dorking roads to the EU limit values Road or Woodcote Green hospital. Road. The worst-case receptors are residential properties at the junction between

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A24 Dorking Road and Ashley Avenue. Acute Sustainability St Helier Improvement in air quality Patients, local Positive M - Baseline air M – Patient H - long Services at Hospital (NO2, PM10 and PM2.5) as a residents and any quality in the visits per day term (over Epsom result of a moderate decrease other vulnerable surrounding decrease by one year) in the number of patients groups (i.e. area is just between 100 attending this Hospital (due to schools, care below the air and 250 decrease in major acute homes) located on quality service provision) and the main access objectives and travelling on B278 Wrythe roads to the EU limit values Lane. hospital. The worst-case receptors are residential properties on B278 Wrythe Lane close to Rose Hill Roundabout.

Acute Sustainability Wider Worsening of air quality (NO2, Patients, local Negative H - Baseline air L - Patient H - long Services at impacts on PM10 and PM2.5) in areas of residents and any quality in the visits per day term (over Epsom air quality existing poor air quality and other vulnerable surrounding increase by one year) sensitive relevant exposure (Wimbledon groups (i.e. area is above between 50 areas and Croydon AQFAs), schools, care the air quality and 100 exceedances of air quality homes) located in objectives and objectives and predicted areas of existing EU limit values exceedances of EU limit poor air quality values (on A23), due to near Croydon

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increases in patients attending University Hospital St George's Hospital and and St George's Croydon University Hospital Hospital (due to decrease in provision of acute services at St Helier Hospital) and likely to drive through Wimbledon and Croydon town centres. Overall change is Negative. Acute Sustainability Epsom Improvement in air quality Patients, local Positive L - Baseline air M - Patient H - long Services at Hospital (NO2, PM10 and PM2.5) as a residents and any quality in the visits per day term (over St Helier result of a moderate decrease other vulnerable surrounding decrease by one year) in the number of patients groups (i.e. area is well between 100 attending this Hospital (due to schools, care below the air and 250 decrease in major acute homes) located on quality service provision) and the main access objectives and travelling by private car or roads to the EU limit values ambulance on A24 Dorking hospital. Road or Woodcote Green The worst-case Road. receptors are residential properties at the junction between A24 Dorking Road and Ashley Avenue.

Acute Sustainability St Helier Worsening of air quality (NO2, Patients, local Negative M - Baseline air L - Patient H - long Services at Hospital PM10 and PM2.5) as a result of residents and any quality in the visits per day term (over St Helier a small increase in the number other vulnerable surrounding increase by one year) of patients attending this groups (i.e. area is just between 50 Hospital (due to increase in schools, care below the air and 100 major acute service provision) homes) located on quality and travelling on B278 Wrythe the main access objectives and Lane. roads to the EU limit values hospital. The worst-case receptors are residential properties on B278 Wrythe Lane close to Rose Hill Roundabout.

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Acute Sustainability Sutton No change in air quality (NO2, Patients, local Neutral M - Baseline air N – No H - long Services at Hospital PM10 and PM2.5) as no residents and any quality in the change in term (over St Helier changes proposed in provision other vulnerable surrounding patient visits one year) of major acute services at this groups (i.e. area is just per day. Hospital. schools, care below the air homes) located on quality the main access objectives and roads to the EU limit values hospital. The worst-case receptors are residential properties on A232 (Sutton AQFA) and on B2230 Brighton Road. Acute Sustainability Wider Negligible overflow of patients Patients, local Negative L - Baseline air N - Patient H - long Services at impacts on to other hospitals outside the residents and any quality in the visits per day term (over St Helier air quality CCG area. The increase in other vulnerable surrounding increase by one year) sensitive patients attending St Helier groups located in area is well less than 50 areas Hospital (due to increase in areas with existing below the air major acute services poor air quality (i.e. quality provision) are unlikely to travel schools, care objectives and through areas of existing poor homes) EU limit values air quality. Overall change is Neutral. Acute Sustainability Epsom Improvement in air quality Patients, local Positive L - Baseline air M - Patient H - long Services at Hospital (NO2, PM10 and PM2.5) as a residents and any quality in the visits per day term (over Sutton result of a small decrease in other vulnerable surrounding decrease by one year) the number of patients groups (i.e. area is well between 100 attending this Hospital (due to schools, care below the air and 250 decrease in major acute homes) located on quality service provision) and the main access objectives and travelling by private car or roads to the EU limit values ambulance on A24 Dorking hospital. Road or Woodcote Green The worst-case Road. receptors are residential properties at the junction between A24 Dorking Road and Ashley Avenue.

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Acute Sustainability St Helier Improvement in air quality Patients, local Positive M - Baseline air M - Patient H - long Services at Hospital (NO2, PM10 and PM2.5) as a residents and any quality in the visits per day term (over Sutton result of a moderate decrease other vulnerable surrounding decrease by one year) in the number of patients groups (i.e. area is just between 100 attending this Hospital (due to schools, care below the air and 250 decrease in major acute homes) located on quality service provision) and the main access objectives and travelling on B278 Wrythe roads to the EU limit values Lane. hospital. The worst-case receptors are residential properties on B278 Wrythe Lane close to Rose Hill Roundabout.

Acute Sustainability Sutton Worsening of air quality (NO2, Patients, local Negative M - Baseline air H - Patient H - long Services at Hospital PM10 and PM2.5) as a result of residents and any quality in the visits per day term (over Sutton a large increase in the number other vulnerable surrounding increase by one year) of patients attending this groups (i.e. area is just more than 250 Hospital (due to increase in schools, care below the air major acute service provision) homes) located on quality and travelling on B2230 the main access objectives and Brighton Road. roads to the EU limit values hospital. The worst-case receptors are residential properties on A232 (Sutton AQFA) and on B2230 Brighton Road.

Acute Sustainability Wider Worsening of air quality (NO2, Patients, local Neutral H - Baseline air N - Patient H - long Services at impacts on PM10 and PM2.5) in areas of residents and any quality in the visits per day term (over Sutton air quality existing poor air quality and other vulnerable surrounding decrease by one year) sensitive relevant exposure (Wimbledon groups (i.e. area is above less than 50 areas AQFAs) and exceedances of schools, care the air quality air quality objectives as a homes) located in objectives and result of increases in patients areas of existing EU limit values attending St George's Hospital poor air quality (due to decrease in provision near Croydon of acute services at St Helier University Hospital Hospital) and likely to drive and St George's through Wimbledon town Hospital

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centre. Improvement in air quality in areas of existing poor air quality and relevant exposure (Croydon AQFAs) and predicted exceedances of air quality limit values (on A23), due to decreases in patients attending Croydon University Hospital (due to increase in provision of acute services at Sutton Hospital) and likely to be diverted from Croydon town centre. Overall change is Neutral.

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D. Green House Gases Assessment Methodology

Greenhouse Gas (GHG) emissions contribute to climate change and are of national importance due to UK national reduction targets. Changes to how the NHS services are delivered across Surrey Downs, Sutton, and Merton Clinical Commissioning Groups (CCGs) have the potential to change emissions of GHGs. These changes have been assessed within the Integrated Impact Assessment (IIA) framework to inform decision makers.

This document details the method of the assessment that has examined the predicted impact on GHG emissions of the proposed changes to NHS services.

The proposed changes have the potential to change the level of GHG emissions in three principle areas: travel; building energy use; and procurement.

At this early stage, there are some activities for which we cannot calculate GHG emissions:

It is unclear how the changes will alter the energy consumption of NHS buildings, and how consumption of consumables (procurement) will be affected. It is assumed that energy use and consumables would be approximately equally for each option, and they have not been quantified at this stage; The new major acute services to be located at Sutton Hospital would result in additional construction emissions. At this stage of assessment, it is not possible to quantify emissions from building construction as the new design of the hospital with construction data if not currently available; The use of ambulances has not been projected for the proposed changes, therefore GHG emissions from ambulance transport has been excluded from all options; It is likely that the changes will affect the travel of NHS staff, visitors, and contractors in a similar manner, however, additional data is required to factor those changes in. Patient activity data was used for 2025 and 2026 (1-year). The data used details the: numbers of patients visiting all local hospitals broken down into service areas (e.g. elective, non-elective, A&E, outpatient, and births); catchment data demonstrating the shortest journey distance for each Local Service Order Administration (LSOA); and population data by LSOA. The data is also split into four scenarios:

Baseline: represents the current use of hospitals in the area Just Epsom: represents the acute services shifting to only be located at Epsom Hospital Just St Helier: represents the acute services shifting to only be located at St Heliers Hospital Just Sutton: represents the acute services shifting to only be located at Sutton Hospital To assess the impact of the prosed changes to the NHS services on GHG emissions, the shift in patients with and without the changes has been compared. The non-acute services at Epsom Hospital and St Helier Hospital have remained the same as the baseline. There were no services at Sutton Hospital in the baseline. The different scenarios modelled some transfer of services to other nearby hospitals (St George's Hospital, Kingston Hospital, Croydon University Hospital, St Peter's Hospital, East Surrey Hospital, and Royal Surrey County Hospital), these changes have been included in the assessment.

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To calculate emissions with and without the changes, the trips per person per year was calculated using the total patient numbers, and the populations based in each catchment. This was then applied to the population of each LSOA, giving the total trips per LSOA. Using the trips and travel distance per LSOA gave the total distance travelled by all patients for each scenario.

The total distance was then apportioned to transport mode using national data (Department for Transport, 2017)2. It was assumed patients would not travel by motorcycle, peddle bicycle, or air transport. The same modal split was applied for all trips, regardless of the originating LSOA or destination hospital. Once the distances had been apportioned to transport mode, BEIS 2018 GHG conversion factors3 were applied per km travelled to estimate emissions, assuming one patient per car. The emissions were estimated with and without the changes, and doubled to account for return journeys, which were assumed to be the same in both directions for all patients. The difference between with and without the changes for each scenario was then calculated.

2 Department for transport (2017), Passenger transport, by mode: annual from 1952 Table TSGB010: https://www.gov.uk/government/statistical-data-sets/tsgb01-modal-comparisons 3 Department for Business, Energy & Industrial Strategy (2018), Conversion factors 2018- Full set: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/715426/Conversion_Factors_2018_- _Full_set__for_advanced_users__v01-01.xls

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E. Travel and Access Methodology

E.1 Technical note on travel and access methodology

Project: SWL Travel Analysis

Prepared by: Craig Walley Date: 20/10/2018

Approved by: Frances Parrott Checked by: Charlotte Reynolds

Subject: Technical Note v2

E.1.1 Phase 1 Methodology Area definition The CCGs of Sutton, Merton, and Surrey Downs were defined as the study area for the assessment. A 15km buffer was created around the study area to create a wider catchment area for the purposes of modelling travel.

Population weighted centroids were extracted for each lower super output area (LSOA) within the 15km buffer area.

The hospitals / site locations for the study were extracted from NHS Choices using the co- ordinates provided in the dataset. These were:

1. Epsom Hospital 2. St Helier Hospital 3. Sutton Hospital 4. Croydon University Hospital 5. East Surrey Hospital 6. Kingston Hospital 7. Royal Surrey County Hospital 8. St George's Hospital 9. St Peter's Hospital A map was produced showing the site locations, the study area, and the 15km buffer.

TRACC Public transport (PT) model generation Timetables from the Traveline National Dataset and Association of Train Operating Companies (ATOC) were imported into the TRACC model for the South West area. The timetables were from quarter two 20184, and included the following modes:

 Bus  Coach  National Rail  Light rail  Tram

4 Please note that for the final IIA report, public transport travel analysis has been updated with data relating to 2020.

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 Tube  Ferry The LSOA centroids for the wider study area were added to the model as origin points. As the maximum external connection distance was set to 800 metres, it was necessary to move a small number of centroids to their nearest PT stop, to ensure they had the potential to return travel times if possible in that time period. Centroids that required moving were mostly rural and outside of the three CCGs in the study area. These were:

- Sutton 025D (E01004114) - Reigate and Banstead 004C (E01030567) - Tandridge 004A (E01030828) - Waverley 012D (E01030942) - Mid Sussex 007C (E01031697) - Mole Valley 012C (E01030557) - Runnymede 008A (E01030677) - Tandridge 004F (E01030861) - Waverley 012D (E01030942) - Chichester 002A (E01031517) - Chichester 002B (E01031518) - Chichester 002C (E01031544) - Chichester 002D (E01031545) - Horsham 010A (E01031611) - Horsham 001D (E01031676) Some moved centroids still had no PT access to a hospital in certain time periods. All centroids had access in one of the time periods indicating possible access.

The 9 hospital locations were then added to the model as the destination points. The TRACC program was run to create estimated travel times between each possible combination of LSOA and hospital. The following parameters were used:

 800m maximum external connection distance (the distance representing a possible walk to a first stop location)  400m internal connection distance (the distance possible to walk when changing services mid-journey)  Walk speed of 4.8kmph  5 minute interchange penalty (a minimum wait value to stop over-optimistic service changes)  All PT modes were included The model was run four times for the following time periods:

 AM Peak – 07:00 to 10:00 hrs  Inter Peak – 10:00 to 16:00 hrs  PM Peak – 16:00 to 19:00 hrs  Off Peak – 19:00 to 23:59 hrs Car and Blue Light Ambulance (BLA) model generation TM-Speeds data (derived from Trafficmaster 2017) 5 was used as the network for the car and BLA model. The dataset utilises speed data returned from Satnav devices, with over 12 billion

5 Please note that for the final IIA report, private car and blue-light ambulance travel analysis has been updated with data relating to 2018.

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data counts for England and Wales included per annum. The data includes detailed Road Routing Information (RRI) including one way systems, banned turns and access restrictions.

The LSOA centroids and hospital locations were again used as the origins and destinations for the modelling. A small number of centroids would not return a travel time, due to their location being adjacent to a motorway or restricted link. These centroids were manually moved to the closest link where it was possible to start a journey. These LSOAs were:

 Hounslow 004C (E01002626)  Lambeth 013C (E01003039)  Runnymede 009C (E01030660)  Runnymede 008A (E01030677)  Spelthorne 004C (E01030736) The car model was run for the time periods above, with the exception of the AM peak time which is set in the dataset to 07:00 to 09:00 hrs, and off-peak period which is set to 00:00 to 04:00 hrs. The calculation was set to return the fastest path between origins and destinations.

BLA travel times were estimated by multiplying the car travel time outputs by 0.9 to create a value 10% faster than the car travel time. This was discussed with colleagues at SECAM and LAS and considered to be a sensible assumption.

Time period definitions and justification

The time periods used for the assessment were chosen to model representative periods for midweek journeys. These were discussed in the inception meeting on the 10th May 2018.

The car / BLA time periods were driven by the segmentation available in the car speeds dataset. This data comes with defined time periods:

 AM Peak – 07:00 to 09:00 hrs (Monday to Friday average)  Inter Peak – 10:00 to 16:00 hrs (Monday to Friday average)  PM Peak – 16:00 to 19:00 hrs (Monday to Friday average)  Off Peak – 00:00 to 04:00 hrs (All week average) The PT analysis was tailored to similar time periods where possible, however the PT model required a day of the week to be specified as opposed to a week or midweek average. Tuesday was chosen for the analysis as this was assumed to be representative of typical midweek transport timetables. The time period differences for PT compared to car were as follows:

 The AM peak was extended to 3 hours (07:00 to 10:00hrs) to align with the 3-hour window in the peak period (16:00 to 19:00hrs).  The Off-peak period was changed to 19:00 to 23:59 hrs due to the highly reduced lack of PT services, particularly trains in the 00:00 to 04:00 hrs period. Output generation Origin Destination travel time matrices were exported from the model for the three modes, for each time period (a total of 12). From here, analysis was conducted to return the minimum travel time from an LSOA to a hospital and the name of the closest hospital (in terms of travel time) to each LSOA. Maps and summary data tables were produced to present the results.

E.1.2 Phase 2 Methodology Phase 2 of the travel analysis looked at two main areas:

 Assessing the differences in journey time for the one site options compared to the baseline.

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 Assessing the travel time changes for the protected characteristic groups to see if these groups experienced any disproportionate impacts. Assessing the one site options against the baseline

To complete this, the travel time data for car and PT generated in Phase 1 was used as the basis of the analysis. The data was processed in a database to only include travel times for the following options:

Epsom Hospital and the six out of area hospitals St Helier Hospital and the six out of area hospitals Sutton Hospital and the six out of area hospitals Once new travel times were generated using just these hospitals as available destinations, we were able to re-create the tables produced in phase one and assess change against the baseline scenario.

Assessing the travel impacts on protected characteristic groups

The phase 1 analysis and the initial options testing was produced by quantifying the number and proportion of the study area population within travel time bands. To assess the impacts on the protected characteristic groups, demographic data representing these groups was gathered from 2016 Mid-Year Population Estimates and Census 2011. Specifically, the datasets used for each group are outlined below:

 Total population – 2016 Mid-Year Estimate data (ONS, 2016)  Population aged 65 and over – 2016 Mid-Year Estimate data (ONS, 2016)  Females aged 16 to 44 – 2016 Mid-Year Estimate data (ONS, 2016)  Male population – 2016 Mid-Year Estimate data (ONS, 2016)  BAME residents – Census 2011  Disabled residents - Population with a long-term health problem or disability (Census 2011)  Deprived population – Indices of Multiple Deprivation (DCLG 2015) were used to define the deprived LSOAs, and once identified the 2016 MYE population figure for that LSOA was used6. The numbers of each group present in each LSOA were quantified using the travel time data into the same output tables showing the number and proportion of each group in the various travel time bands. This enables assessment against the baseline scenario during the Integrated Impact Assessment (IIA).

6 Please note that for the final IIA report, deprivation analysis has been updated with data relating to 2018.

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E.2 Key questions

Frequently Asked Questions – Travel and access

1. What is the study area for the Integrated Impact Assessment (IIA)? The key study area for this work includes Sutton, Merton and Surrey Downs Clinical Commissioning Groups (CCGS) catchment areas.

A wider study area (15km buffer) was created around the CCGs study area to create a wider catchment for the purposes of modelling travel and transport. The wider study area allows us to review journey times from outside

2. How have you analysed the population data? Lower Super Output Areas (LSOAs) were chosen as an appropriate way to analyse the CCGs populations. This is the lowest standard geography that many of the socio-demographic datasets such as deprivation are available.

 Is the IIA looking at impacts on other providers? The Improving Healthcare Together Programme has set up a provider impact group to review any potential impact on other providers for each of the proposed options.

The hospitals / site locations used for looking at potential impacts upon other providers includes:

 Epsom Hospital  St Helier Hospital  Sutton Hospital  Croydon University Hospital  East Surrey Hospital  Kingston Hospital  Royal Surrey County Hospital  St George's Hospital  St Peter's Hospital Any relevant data on provider impact will be shared and if relevant used in the IIA.

 What software is the IIA using to undertake its travel analysis work? TRACC is an industry standard software which uses timetables from the Traveline National Dataset and Association of Train Operating Companies (ATOC).

Timetables were imported into the TRACC model for the South West area. The timetable files provide a complete snapshot of operational timetables for the period represented.

 Which modes of transport timetables were used and for what years? The timetables were from quarter two 20187, and included the following modes:

7 Please note that for the final IIA report, public transport travel analysis has been updated with data relating to 2020.

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 Bus  Coach  National Rail  Light rail  Tram  Tube  Ferry This is the most recently available timetable data, and the modes represent all of the public transport options in the dataset.

 What are the time periods that you have based the travel analysis on? The model was run four times for the following time periods:

 AM Peak – 07:00 to 10:00 hrs*  Inter Peak – 10:00 to 16:00 hrs  PM Peak – 16:00 to 19:00 hrs  Off Peak – 19:00 to 23:59 hrs

These were chosen to align with the time periods provided in the car speeds dataset. These periods are provided in the dataset to give a good representation of the different travel time periods throughout the day, as differences are usually seen in the peak periods for example. The only differences between the PT and car analysis were:

 The AM peak was extended to 3 hours (07:00 to 10:00hrs) to align with the 3-hour window in the peak period (16:00 to 19:00hrs).  The off-peak period was changed to 19:00 to 23:59 hrs due to the highly reduced lack of PT services, particularly trains in the 00:00 to 04:00 hrs period.

*The car model was run for the time periods above, with the exception of the AM peak time which is set in the dataset to 07:00 to 09:00 hrs, and off-peak period which is set to 00:00 to 04:00 hrs.

 What are the time periods that you have based the travel analysis on? The time periods for all modes were chosen to model representative periods for midweek journeys.

These times are derived from the availability of segmentation in the car speed dataset, and also because they give a good representation of the different travel time periods throughout the day, as differences are usually seen in the peak periods for example.

Midweek journeys were modelled as this period tends to be busier and would give a worst-case scenario. Also, more journeys to hospitals happen during the midweek period so this would be more representative.

The Patient Transport analysis was tailored to similar time periods where possible, however the Patient Transport model required a day of the week to be specified as opposed to a week or midweek average.

A day of the week needs to be specified in the Patient Transport model, whereas this is not possible for the car or Blue Light and Ambulance model.

 Why is Tuesday chosen as the day for travel and transport analysis?

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Tuesday was chosen for the analysis as this was assumed to be representative of typical midweek transport timetables

 Why are there different time periods chosen for public transport compared to car travel? The time period differences for public transport compared to car were as follows:

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F. Background data collected for travel and access analysis

F.1 Data sources

Table 11: Data received from Travel and Access Working Group or sourced by Mott Macdonald as a result of requests at the Working Group 2 Data source Received from Date received Notes/comments on how data will be used Reliability statistics relating Ashley Field 08/02/2019 Data currently under consideration as to Metrobus 21 service ‘21’ not included as a route that serves any of three hospital sites according to ‘plan my journey’ website. Reliability statistics relating Ashley Field 08/02/2019 Used as useful context to determine to Stagecoach 479 service that 179 Sunday service to Epsom (Sunday only) Hospital is reliable and there is no real variance to timetabled running. Concessionary Travel Ashley Field 08/02/2019 Used as useful context and evidence Consultation Summary that elderly and disabled residents in Analysis Surrey find public transport access important in order to access hospitals. Highlights that older and disabled residents may be more reliant on PT.. Consultation Summary Ashley Field 08/02/2019 Used as useful context and evidence Report that elderly and disabled residents in Surrey find public transport access important in order to access hospitals. Travel Analysis Report – Phil Crockford 04/02/2019 Statistics around reliability of service London Borough of Sutton and number of boarding and alighting passengers for services within Sutton used to justify connectivity of Sutton hospital by PT. Annual Authority Monitoring Phil Crockford 04/02/2019 Used as useful context for transport Report – London Borough of analysis. Sutton Parking information relating Eric Munro 31/01/2019 Information used to assess current to Sutton hospital parking provision and charges for staff, patients and visitors. Combined service frequency Sourced by MM using Public 06/02/2019 Used to highlight the level of PT plots Transport timetables provision at stops to add an extra dimension to the travel time based quantitative assessment. These maps show areas with less stops, and also those stops with less services per hour Car / van availability data Sourced by MM from census 08/02/2019 Used in the additional analysis section 2011 data at LSOA level of the travel chapter to address calls for analysis to include car ownership levels for residents. This will link to deprivation and PT availability analysis to assess if residents in areas of low car ownership may be adversely affected. Parking information relating Eric Munro 29/01/2019 Information used to assess current to Epsom and St Helier parking provision and charges for staff, hospitals patients and visitors.

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Information on future travel Lucy Simpson 05/03/2019 Used as useful context for the current plans in Merton and Sutton and proposed travel plans in the local areas. Information relating to Sutton Lucy Simpson 05/03/2019 Used as useful context for the current Link and proposed travel plans in the local areas. Information relating to future Chris Chowns 04/02/2019 Used as useful context for the current transport plans and town and proposed travel plans in the local centre regeneration areas. A&E attendance data for James Glossop 04/03/2019 Used to justify study area selection. ESTH sites for 2017-2018 TfL Public Transport Sourced by MM from TfL 01/02/2019 Used to evidence relative public Accessibility Level (PTAL) website transport accessibility surrounding data Sutton and St Helier hospital sites only (as data not available for Epsom hospital) compared to Greater London. Frequency of services and Sourced by MM from Epsom Used to determine which site has the location of bus stops at and St Helier University best direct public transport accessibility ESTH hospital sites Hospitals Trust ‘plan my across the two days journey’ website iBus Data P1 to P10 2018 Sourced by MM from TfL Used as useful context around the website reliability and average travel speeds for TfL services to and from hospital sites. Useful context to demonstrate that routes serving hospitals run to different speeds across weekday and weekend periods. Can be used to evidence quicker PT travel times on Sundays. Data file containing current Phil Crockford 19/03/2019 Used as useful context for the current and future provision of major and proposed travel plans in the local transport schemes by areas. London Borough Data file containing car Phil Crockford 19/03/2019 Used in the additional analysis section ownership data by Ward of the travel chapter to address calls within Sutton for analysis to include car ownership levels for residents. This will link to deprivation and PT availability analysis to assess if residents in areas of low car ownership may be adversely affected. Email detailing future Lucy Simpson 13/03/2019 Currently under consideration - will schemes that may affect likely be used as the basis for further future accessibility. Also research into the schemes to mention that Sutton Link determine potential future accessibility consultation report should be for each site option available and of March. Staff Shuttle Bus usage data Eric Munro 14/03/2019 To be used in the analysis of potential mitigations. Modal split data for Eric Munro 04/03/2019 Useful context to justify the relative patients/staff/visitors in terms importance of public transport of their travel to the three accessibility based on current hospital sites accessibility. Data surrounding current Eric Munro 04/03/2019 To be used in the analysis of potential and expected use of shuttle mitigations. bus for staff and patients/visitors

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Table 12: Data and/or information requested from Travel and Access Working Group members Data/information Requested from Date requested Notes/comments on how data will be used Information surrounding Eric Munro 04/03/2019 To determine whether any of proposed changes to parking the sites would be better to accommodate increased suited to deal with additional demand traffic and demand for parking. Information regarding Eric Munro 04/03/2019 To determine the numbers of numbers of staff who work in staff would be affected by acute services and how reconfiguration of services many acute services staff and travel/parking currently park at the hospital implications of this for staff. sites

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F.2 Utilisation maps These maps have been used to test the catchment areas for the hospitals for five different types of hospital care (Accident and Emergency, elective, non-elective, outpatients and maternity) for areas within the primary and wider study area.

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Figure 1: Annual (2017-2018) number of A&E attendances at ESTH sites

Source: Mott Macdonald based on data from PA Consulting

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Figure 2: Annual (2017-2018) number of elective admissions at ESTH sites

Source: Mott Macdonald based on data from PA Consulting

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Figure 3: Annual (2017-2018) number of non-elective admissions at ESTH sites

Source: Mott Macdonald based on data from PA Consulting

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Figure 4: Annual (2017-2018) number of outpatient attendances at ESTH sites

Source: Mott Macdonald based on PA Consulting

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Figure 5: Annual (2017-2018) number of maternity attendances at ESTH sites

Source: Mott Macdonald based on data from PA consulting

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Figure 6: Annual (2017-2018) A&E attendance rate at ESTH sites

Source: Mott Macdonald based on data from PA consulting, and 2017 mid-year population estimates

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Figure 7: Annual (2017-2018) elective admission rates at ESTH sites

Source: Mott Macdonald based on data from PA consulting, and 2017 mid-year population estimates

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Figure 8: Annual (2017-2018) non-elective admission rates at ESTH sites

Source: Mott Macdonald based on data from PA consulting, and 2017 mid-year population estimates

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Figure 9: Annual (2017-2018) outpatient attendance rates at ESTH sites

Source: Mott Macdonald based on data from PA consulting, and 2017 mid-year population estimates

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Figure 10: Annual (2017-2018) maternity attendance rates at ESTH sites

Source: Mott Macdonald based on data from PA consulting, and 2017 mid-year population estimates

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F.3 Hospital catchment maps The maps are based on the hospital that is the closest by minimum travel time, during the Tuesday interpeak period, for travel by public transport and car/blue light ambulance.

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Figure 11: Closest hospital by minimum travel time by public transport – baseline

Source: Mott Macdonald based on Association of Train Operating Companies (ATOC) and Traveline data,

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Figure 12: Closest hospital by minimum travel time by public transport for the wider study area – baseline8

8 In some instances, due to the size of the LSOA area and availability of transport modes areas which appear close to a particular hospital on the map may in fact be closer to another hospital. For example, around St Peter’s Hospital there are those who in fact have Kingston Hospital as their nearest hospital as it is a walk to a train station and a single train journey totalling 75 minutes while travelling to St Peters would involves a walk, and three separate buses, totals 104 minutes.

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Source: Mott Macdonald based on ATOC and Traveline data

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Figure 13: Closest hospital by minimum travel time by public transport – Epsom and out of area hospitals

Source: Mott Macdonald based on ATOC and Traveline data

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Figure 14: Closest hospital by minimum travel time by public transport - Sutton and out of area hospitals

Source: Mott Macdonald based on ATOC and Traveline data

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Figure 15: Closest hospital by minimum travel time by public transport – St Helier and out of area hospitals

Source: Mott Macdonald based on ATOC and Traveline data

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Figure 16: Closest hospital by minimum travel time by car or blue light ambulance – baseline

Source: Mott Macdonald based on TM Speeds data

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Figure 17: Closest hospital by minimum travel time by car or blue light ambulance for the wider study area – baseline

Source: Mott Macdonald based on TM speeds data

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Figure 18: Closest hospital by minimum travel time by car or blue light ambulance – Epsom and out of area hospitals

Source: Mott Macdonald based on TM speeds

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Figure 19: Closest hospital by minimum travel time by car or blue light ambulance – Sutton and out of area hospitals

Source: Mott Macdonald based on TM speeds data

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Figure 20: Closest hospital by minimum travel time by car or blue light ambulance – St Helier and out of area hospitals

Source: Mott Macdonald based on TM speeds data

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F.4 Deprivation analysis maps

Figure 21: Areas within the primary study area that fall within the two most deprived quintiles

Source: Mott Macdonald based on Index of Multiple Deprivation, 2019

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F.5 Study area maps

Figure 22: Primary study area

Source: Mott Macdonald

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Figure 23: Wider study area

Source: Mott Macdonald

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F.6 Parking costs

Table 13: ESTH parking costs Time Cost

Up to 20 minutes £ Free

Up to 1 hour £3.00

Up to 2 hours £5.00

Up to 3 hours £6.50

Up to 4 hours £8.00

Up to 5 hours £10.00

Up to 6 hours £14.50

More than 6 hours (daily maximum) £17.00

Source: ESTH website

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G. Travel and access baseline data

G.1 Demographic density maps 1. For each of the seven additional demographic groups, demographic maps have been produced. For females aged 16 to 44, those with a long-term health problem or disability, those aged 65 and over, males, those from Black, Asian and Minority Ethnic communities and unpaid carers, population density maps have been produced. A map showing the areas within quintiles one and two for deprivation can be found in section E.6. There are a total of six maps in this section.

Figure 24: Population density of females aged between 16 and 44

Source: Mott Macdonald based on 2016 mid-year population estimates

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Figure 25: Population density of those living with a long-term health problem or disability

Source: Mott Macdonald based on 2011 Census

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Figure 26: Population density of those aged 65 and over

Source: Mott Macdonald based on 2016 mid-year population estimates

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Figure 27: Population density of male residents

Source: Mott Macdonald based on 2016 mid-year population estimates

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Figure 28: Population density of Black, Asian and Minority Ethnic residents

Source: Mott Macdonald based on 2011 Census

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Figure 29: Population density of those providing 20 or more hours of unpaid care a week

Source: Mott Macdonald based on 2011 Census

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H. Results of travel and access analysis

Please see the following sub-appendices reports for full data and maps presenting:

H.1 Improving Health Together – Travel and Access Analysis: Blue Light Ambulance Summary data tables presenting the overall findings at 30 minutes and 15 minutes for blue light ambulance across the options and across the four time periods. This includes summary tables for the protected characteristics explored as part of this analysis. Tuesday AM peak baseline and options data - maps and tables. Tuesday IP baseline and options data - maps and tables. Tuesday PM peak baseline and options data - maps and tables. Tuesday OP baseline and options data - maps and tables. Weekend baseline data and options data

H.2 Improving Health Together – Travel and Access Analysis: Car Summary data tables presenting the overall findings at 30 minutes and 15 minutes for car across the options and across the four time periods. This includes summary tables for the protected characteristics explored as part of this analysis. Tuesday AM peak baseline and options data - maps and tables. Tuesday IP baseline and options data - maps and tables. Tuesday PM peak baseline and options data - maps and tables. Tuesday OP baseline and options data - maps and tables. Weekend baseline data and options data

H.3 Improving Health Together – Travel and Access Analysis: Public Transport Summary data tables presenting the overall findings at 30 minutes and 15 minutes for Public Transport across the options and across the four time periods. This includes summary tables for the protected characteristics explored as part of this analysis. Tuesday AM peak baseline and options data - maps and tables. Tuesday IP baseline and options data - maps and tables. Tuesday PM peak baseline and options data - maps and tables. Tuesday OP baseline and options data - maps and tables. Weekend baseline data and options data

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I. Initial Equality Scoping Report

The full Initial Equality Scoping Report can be found at: https://improvinghealthcaretogether.org.uk/document/initial-equalities-analysis-of-major-acute- services-august-2018/

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J. Public Sector Equality Duty (PSED)

The PSED is a legal obligation for public sector organisations to consider how they could positively contribute to the advancement of equality and good relations and requires equality considerations to be reflected in the design of policies and delivery of services9. The equality duty outlines the duties of organisations to exercise their functions to have due regard to the need to:  Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.  Advance equality of opportunity between people who share a protected characteristic and those who do not.  Foster good relations between people who share a protected characteristic and those who do not.10 An Integrated Impact Assessment (IIA) is a component of policy-making which helps to assist decision-makers in meeting their public sector duty. The IIA itself is not subject to the PSED. However, the IIA is a process used by some public sector bodies to provide them with the information and evidence to ensure that their decisions and conduct conforms with PSED requirements. The IIA assesses disproportionate impacts on the protected characteristic groups covered by the Act, through engagement and desk analysis, and considers the extent to which the three aims of the Act are upheld. This provides decisions-makers with the information necessary to make modifications, mitigations or enhancements in order to fulfil their PSED requirements. For this IIA, the thee aims of the Act were specifically discussed with local community residents representing a number of protected characteristics, during focus group engagement sessions. Participants were asked the following questions: 1. Is there anything about these IHT proposals which is unfair, puts you at a disadvantage compared to others or which you feel discriminates against you? a. Are other equality groups in the community disadvantaged or discriminated against because of these proposals? b. Is there anything about these proposals which would reduce the quality of care you would receive or lead to worse health outcomes? c. What about disabled people, is there anything about any of the options which could make access to services more difficult for people with disabilities? Which sort of disabilities and how? 2. Is there anything about these proposals which may fail to meet your needs or the needs of others like you? a. Are there any other groups whose needs you feel they may fail to meet? 3. Is there anything about these proposals which favours some groups in the community more than others, and gives them an unfair advantage?

9 Equality and Human Rights Commission (2019) ‘Public Sector Equality Duty’. Available at: https://www.equalityhumanrights.com/en/advice-and-guidance/public-sector-equality-duty 10 UK Govt (2010) ‘Equality Act 2010’ – See: https://www.legislation.gov.uk/ukpga/2010/15/section/149

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a. Could this create bad relations or issues between different groups in the community? The following summarises the information gathered relating to three aims of the PSED which has been covered more generally throughout the IIA Report.

Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. This IIA report has not identified any evidence which would suggest that any of the proposed options for change would result in the worsening of harassment or victimisation for protected characteristic groups within the local community. Equally, it has not identified any evidence that these options may improve the situation for local community groups in terms if harassment and victimisation. However, those who participated in the focus groups, did feel that increased journey times to acute services could result in discrimination for some equality groups. In particular, it was felt that these were likely to experience disproportionate effects on the basis of difficulties they could experience in travelling longer distances. Key groups identified include those listed below. It should be noted however, that many participants felt that all residents in the local community would be equally disadvantaged by any change to journey time.  Older people and disabled people (including mental health) - who may have difficulties in terms of mobility, clarity around options available to travel to acute services, and stress when travelling longer distances and to a new hospital.  Pregnant women and parents of young children – who may find it physically difficult and mentally stressful to travel longer journeys.  BAME community – specifically Roma, Gypsy Traveller community who tend to be transient and who may find the further distances to travel to an acute service a disincentive to use services. Advance equality of opportunity between people who share a protected characteristic and those who do not. In advancing the equality of opportunity between people who share a protected characteristic and those who do not, the Equality Act outlines that due regard be given to: a) remove or minimise disadvantages suffered by persons who share a relevant protected characteristic that are connected to that characteristic; b) take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it; c) encourage persons who share a relevant protected characteristic to participate in public life or in any other activity in which participation by such persons is disproportionately low. The IIA has identified that options for change are likely to bring about improvements to both acute services and district services and as such are likely to bring about improvements to patient outcomes and care. This in turn is likely to have a greater impact on groups who have a disproportionate need for these services. As such, the options for change could advance health equalities for the following protected characteristics:  Children and young people (under 16s and those aged 16-24)  Disabled people  Gender reassignment  Pregnancy and maternity  Race and ethnicity  Sex

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 Sexual orientation  People living in deprived areas The IIA identifies that the extent to which these advancements are realised is dependent on the quality and timeliness of engagement and communication with these groups. It will also be dependent on supporting access for particular groups who may be disadvantaged by longer journey times. Foster good relations between people who share a protected characteristic and those who do not. The Equality Act outlines that having due regard to the need to foster good relations between persons who share a relevant protected characteristic and persons who do not involves having due regard to the need to: a) tackle prejudice, and b) promote understanding. The evidence explored as part of this IIA has not identified any evidence which suggests that the changes would make any significant steps in tackling prejudice or promoting understanding between those with a protected characteristic and those who do not. It has also not identified any evidence to suggest that any of the changes would worsen current relations within the community.

In addition to the points discussed above, Mott MacDonald also discussed with stakeholders whether they felt that certain groups should be treated more favourably or differently in order to ensure service provision is adequate and fair to them. While the majority of those engaged with did not feel that any group should be treated differently, there were some participants who identified that the following groups may need different treatment or should be favoured:

 Disabled people (including mental health illness) – felt that this group are especially vulnerable in society and may need more support around the care pathway and how to access services.  Older people – again this group was felt to be a very vulnerable group who may need additional support in ensuring they can access acute services where these are provided in a location which is new to them.

Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment 1 Appendices

Table 14: Engagement activities with protected characteristic groups Additional engagement being sort Protected characteristic Scoped in to the equalities analysis Engagement completed for the IIA for the IIA 1. In-depth telephone interview with 12 clinicians The initial scoping analysis identified that: and CCG representatives, and 6 representatives of key user groups were undertaken to explore 1. Children and young people (those aged 16 evidence on disproportional or differential need and under and those aged 16-24) have a across all equality groups in the local area. disproportionate need/use of accident and emergency services, obstetrics and 2. Two focus groups, one in Sutton and one in paediatrics. Surrey Downs with people aged 65 years and Age older (attended by 10 and 7 residents 2. Older people (those aged 65+) have a respectively). disproportionate need/use of accident and emergency services, acute medicine and 3. A focus group with those aged 16-24 years in emergency general surgery. They also have a Surrey Downs (attended by 11 residents). differential need for accident and emergency when compared with others. 4. A focus group with parents in Surrey Downs (attended by 9 residents). Further engagement planned with those 1. In-depth telephone interview with 12 clinicians with a learning disability to reflect and CCG representatives, and 6 representatives differences in experience to other disabled of key user groups were undertaken to explore groups and a lack of representation at the The initial scoping analysis identified that evidence on disproportional or differential need groups conducted to date. disabled people have a disproportionate across all equality groups in the local area. Disability need/use of accident and emergency services, Will be completed through attendance at acute medicine, obstetrics and paediatrics. 2. Two focus groups with people with a Limiting the Valuing People forum in Surrey Downs Long-Term Illness (LLTI), one in Merton and one which is attended by those with a learning in Surrey Downs (attended by 8 and 9 residents disability as well as parents, carers and respectively). professionals support this group. Further engagement with the LGBT+ community is being explored. The Mott In-depth telephone interview with 12 clinicians and The initial scoping analysis identified that MacDonald team are contacting CCG representatives, and 6 representatives of those who have or are undergoing gender stakeholders in the local community to Gender reassignment key user groups were undertaken to explore reassignment have a disproportionate seek their support in setting up a focus evidence on disproportional or differential need need/use of accident and emergency services. group. One representative of a key user across all equality groups in the local area. group has been interviewed as part of this work. The initial scoping analysis scoped out this Marriage and civil group as evidence does not indicate any In-depth telephone interview with 12 clinicians and

partnership disproportionate or differential need for this CCG representatives, and 6 representatives of protected characteristic group. key user groups were undertaken to explore

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Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment 2 Appendices

evidence on disproportional or differential need across all equality groups in the local area. 1. In-depth telephone interview with 12 clinicians and CCG representatives, and 6 representatives of key user groups were undertaken to explore evidence on disproportional or differential need across all equality groups in the local area.

The initial scoping analysis identified a 2. A focus group in Merton with females aged 18- Pregnancy and maternity disproportionate need/use amongst this group 44, from a BAME background (attended by 8 for acute medicine, obstetrics and paediatrics. residents).

3. A focus group in Sutton with females aged 18- 44 (attended by 10 residents).

4. A focus group with parents in Surrey Downs (attended by 9 residents). 1. In-depth telephone interview with 12 clinicians and CCG representatives, and 6 representatives of key user groups were undertaken to explore The initial scoping analysis identified a evidence on disproportional or differential need disproportionate need/use of accident and Race across all equality groups in the local area. emergency services, acute medicine and

obstetrics amongst this group. 2. Two focus groups, one in Merton and one in Sutton with people from a BAME background (both groups attended by 9 residents). 1. In-depth telephone interview with 12 clinicians The initial scoping analysis scoped out this and CCG representatives, and 6 representatives group as evidence does not indicate any Religion and belief of key user groups were undertaken to explore disproportionate or differential need for this evidence on disproportional or differential need protected characteristic group. across all equality groups in the local area. 1. In-depth telephone interview with 12 clinicians and CCG representatives, and 6 representatives The initial scoping analysis identified a of key user groups were undertaken to explore disproportionate need/use amongst this group evidence on disproportional or differential need for acute medicine (males) and obstetrics Sex across all equality groups in the local area. (females). It also identified a differential need

for accident and emergency services and 2. All 12 focus groups undertaken at phase 2 of emergency general surgery. this work were attended by a mix of males and females to address difference by sex. The initial scoping analysis identified a 1. In-depth telephone interview with 12 clinicians Further engagement with the LGBT+ Sexual orientation disproportionate need/use for accident and and CCG representatives, and 6 representatives community is being explored. The Mott emergency services amongst this group. of key user groups were undertaken to explore MacDonald team are contacting

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Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment 3 Appendices

evidence on disproportional or differential need stakeholders in the local community to across all equality groups in the local area. seek their support in setting up a focus group. One representative of a key user group has been interviewed as part of this work. Additional groups explored Mott MacDonald are seeking to undertake additional engagement with carers The initial scoping analysis scoped out as following discussion with the Steering evidence did not indicate any disproportionate Group who feel that the impact of any or differential clinical need for this protected change on this group needs to be characteristic group. However, following explored further. 1. In-depth telephone interview with 12 clinicians discussion with stakeholders this group has and CCG representatives, and 6 representatives been explored within the IIA as it has been Mott MacDonald is seeking to conduct a Carers of key user groups were undertaken to explore argued that this group may be focus group with carers via local evidence on disproportional or differential need disproportionately impacted by changes to community representatives. across all equality groups in the local area. services when considering the likely travel impact and that this group have been known to Attendance at the Valuing People Forum prioritise the care of this they care for over will allow the team to hear the views of their own needs. those caring for people with a learning disability, but an additional focus group is also being sort. 1. In-depth telephone interview with 12 clinicians It was raised by local community and CCG representatives, and 6 representatives representative that additional groups with of key user groups were undertaken to explore those from the second highest quintile of evidence on disproportional or differential need The initial scoping analysis identified a deprivation may be beneficial. The Mott across all equality groups in the local area. Deprivation disproportionate need/use for all acute MacDonald team will therefore be seeking

services amongst this group. to undertake an additional focus group 2. Two focus groups, one in Merton and one in with residents from the second highest Sutton with those living in areas within the highest quintile of deprivation in Merton (targeting quintile of deprivation (attended by 6 and 12 the wards of St Helier and Ravensbury). residents respectively) Source: Mott MacDonald

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Mott MacDonald | Improving Healthcare Together 2020-2030 Integrated Impact Assessment 4 Appendices

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