7 Date Wednesday, 10 April 2019 Presenter Rachel Donovan, NHS

Paper: 7

Date Wednesday, 10 April 2019

Title of paper Practice Boundary Change request

Presenter Rachel Donovan, NHS England Author Rachel Donovan, Assistant Head of Primary Care Commissioning. Responsible Neha Unadkat, Deputy Managing Director – Integrated and Primary Director Care Clinical Lead Name and Role Items are only confidential if it is in the public Confidential Yes ☐ No  interest for them to be so

The Group is asked to: Note the update from the Task and Finish group, set up to review five recent practice boundary change requests. Agree the recommended action for the following applications: 1. Crown Street Surgery boundary increase 2. The Vale Surgery boundary reduction 3. The Cloister Road boundary reduction

Summary of purpose and scope of report Over the past few months Ealing CCG have received several applications from practices applying to change their practice boundary areas. The following applications have been received: • Elthorne Park Surgery (area reduction) • The Vale Surgery (area reduction) • Florence Road (area reduction) • Cloister Road Surgery (area reduction) • Crown Street Surgery (area increase) Ordinarily these applications would be considered independently, however, due to the number of requests submitted the Primary Care Committee has asked for a Task and Finish group to be set up so that these applications can be reviewed together to establish any interdependences and the overall impact on primary care provision and potential patient access implications. The group was held on 11th February 2019. The group was provided with the practice applications, maps, capacity and performance data of those practices that have been considered as being most affected and ward level demographic data.

Paper: 7

The group was asked to consider each application having regard to the interdependences between the application and cosier the following : a) The reasons why each practice is applying to change their practice area. b) What other options the practices have considered prior to the application being submitted to assist with the difficulties. c) Practice completion of sufficient patient engagement d) The impact that the reduced area would have on patient access to general medical services; e) Development of EQIAs, taking into account demographic information from affected wards and considering any disproportionate impact on patients with protected characteristics and health inequalities. f) Other practices’ boundaries and potential impact on neighbouring practices. Taking into consideration any known changes and quality and capacity information about those practices. g) and the associated impact of the application not being approved. The group also noted that Ealing Park Surgery had recently applied to close their list which had been considered by the Quality group previously (the group asked for a meeting to be set up with the practice to discuss the other options they had considered/any other support that could be offered). The group discussed each application and recommended the following actions: a) When any application for boundary change is agreed it shall be on the principle that the practice will not remove any existing patients that live inside the current boundary but outside the new boundary. The practice will also be expected to register dependents of those existing patients. b) Elthorne Park & Florence Road – It was agreed that due to the potential impact these reductions will have on these practice and other practices in the area, including Ealing Park Surgery, we need a discussion with all three, and the wider network to properly assess this impact. This will help inform a Quality Impact Assessment and Equality and Health Inequalities Analysis for these proposals. c) Quality Impact Assessments (QIA) and Equality and Health Inequalities Analysis (EHIA) will be completed for The Crown Street Surgery and The Vale Surgery. The group agreed that subject to no significant risks identified through the QIAs and EHIAs, they recommend that these changes be approved by the PCC. d) Quality Impact Assessments and Equality Health will also be completed for Cloister Road Surgery, however a concern was identified with part of the reduction and the impact it would have on two small practices towards the South East of the excluded area. Therefore it is proposed that the excluded area be reduced , and only the northern part of the area reduction be approved.

The following papers are now presented to the Primary Care Committee for decision: 1. Crown Street Surgery boundary increase 2. The Vale Surgery boundary reduction

Paper: 7

3. The Cloister Road boundary reduction

The committee is asked to agree the recommended actions set out in the papers.

Quality & Safety/ Patient Engagement/ Impact on patient services: The group considered the quality impact of these proposals and the patient engagement undertaken by the practices. QIAs have been completed for each proposal.

Finance, resources and QIPP N/a

Equality / Human Rights / Privacy impact analysis The group considered available demographic information from affected wards and considering any disproportionate impact on patients with protected characteristics and health inequalities. A Equality and Health Inequalities Analysis (EHIA) will be completed for each application.

Risk Mitigating actions

Supporting documents 1. Crown Street Surgery boundary increase 2. The Vale Surgery boundary reduction 3. The Cloister Road boundary reduction

Governance and reporting N/A Committee name Date discussed Outcome Name DD/MM/YYYY

E85680 Cloister Road Surgery - Application to reduce the practice catchment area

1. Practice profile and context

1.1. Cloister Road Surgery is a two-partner GMS practice in the Acton area (Dr Sukumaran and Dr Dhall). They have been rated as ‘Good’ by the CQC at the last inspection in April 2016.

1.2. The practice opening hours are as follows;

Day Opening Hours Surgery Hours Monday 0800-1730 0830-1120, 1430-1720 Tuesday 0800-1730 0830-1120, 1430-1720 Wednesday 0800-1730 0830-1120, 1430-1720 Thursday 0800-1730 0830-1120, 1430-1720 Friday 0800-1730 0830-1120, 1430-1720 Saturday Closed Closed Sunday Closed Closed

1.3 The registered list size of the practice is 10523 as of 1st October 2018. There has been a 37.11 % increase from April 2013 to October 2018. This is compared to an Ealing average increase of 7% from 2013 (409,906) to 2018 (438,769).

Year List size April 2013 7675 April 2014 7739 April 2015 8429 April 2016 8962 April 2017 9627 April 2018 10303

2. Practice request to reduce boundary area

2.1. In line with the NHS England Primary Care Policy and Guidance Manual (PGM) the practice submitted an application (appendix 1) to reduce their practice area.

2.2. The proposed reduction is shown below.

1 | P a g e

Note: Outer blue boundary line represents the practices current area. The inner blue non lined area represents the practices proposed reduced catchment area.

2.3. The area being excluded is mainly the area of North Action above the A4O.

2.4. The reasons for the application to reduce their boundary are set out by the practice in their application and are summed up as follows;

 The practice reports capacity problems in light of 2 failed applications for premises extensions.  Reports of stretched clinical capacity from significant list size growth

2.5. Should the practice’s application be approved, patients that currently fall within the practice’s area but do not fall within the new area would continue to stay registered with the practice. The practice would also continue to register children and dependent family members of registered patient who live within this area.

3. Local Practices

3.1. There are 3 practices that are likely to be most affected by the proposed reduction; one Brent Practice, one Hammersmith and Fulham practice and one Ealing practice. These practices have open lists and are accepting new patients. A list of these practices along with their latest patient experience and CQC ratings is at appendix 3.

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3.2 The maps at appendix 2 shows the distribution of patients registered with Cloister Road Surgery and the position of the surrounding practices.

3.3 The application has been discussed with Brent CCG. They have confirmed that there is sufficient coverage and capacity in the area, due to its proximity to Park Royal Medical Centre. A new Health Centre in Central Middlesex Hospital, with ability to significantly increase capacity.

4 Ealing Boundary Task and Finish Group

4.2 Over the past few months Ealing CCG have received several applications from practices applying to change their practice boundary areas. Ordinarily these applications would be considered independently, however, due to the number of requests submitted the Primary Care Committee has asked for a Task and Finish group to be set up so that these applications can be reviewed together to establish any interdependences and the overall impact on primary care provision and potential patient access implications.

4.3 The group was held on 11th February 2019. The group was provided with the practice applications, maps, capacity and performance data of those practices that have been considered as being most affected and ward level demographic data.

4.4 The group was asked to consider each application having regard to the interdependences between the application and cosier the following:

a) The reasons why each practice is applying to change their practice area. b) What other options the practices have considered prior to the application being submitted to assist with the difficulties. c) Practice completion of sufficient patient engagement d) The impact that the reduced area would have on patient access to general medical services; e) Development of EQIAs, taking into account demographic information from affected wards and considering any disproportionate impact on patients with protected characteristics and health inequalities. f) Other practices’ boundaries and potential impact on neighbouring practices. Taking into consideration any known changes and quality and capacity information about those practices. g) The associated impact of the application not being approved.

4.5 For Cloister Road Surgery the group recommended that, subject to no further risk identified from a Quality Impact Assessment and Equality and Health Inequalities Analysis, part of the area reduction is approved. The proposed revised area is shown in the map below;

3 | P a g e

The group took the following factors into account:

1. The practice has experienced significant list growth over the last 5 years and is struggling with space within their current premises. This is affecting the practices ability to maintain high standards of care to its current patients. 2. The reduction would allow the practice to stabilise its list and concentrate on improving the care it provides to its existing patients. There is concern that if the practice application is rejected they will be unable to maintain standards of care, due its limited ability to increase clinical capacity. 3. There was concern about the effect the proposed reduction would have on the two small practices south west of the excluded area. 4. The northern part of the excluded area is covered by the new Park Royal Medical Centre, across the Brent border. This practice has the capacity for significant list size growth.

The Quality Impact Assessment and Equality and Health Inequalities Analysis raised an additional concern that the reduction would mean that patients residing in a section of the excluded area (Appendix 2, Map 5) will only have one choice of local GP practice; Park Royal Medical Centre in Brent. There may be other practices further afield, that have large practice boundaries that partly encompasses this area. However, patients would have to travel over a mile to access these surgeries.

5 Committee decision

3.2. Any changes to the practice area must be considered as a variation to the GMS contract. The PGM states that in considering an application, commissioners should have regard to other

4 | P a g e

practices’ boundaries, patient access to other local services and in general other health service coverage within a location.

3.3. If the decision is made to approve the application, the practice contact variation will be drawn up to reflect the change. The practice will be asked to advertise the change on their website and practice leaflet.

3.4. If the decision is made to reject the application, the practice will be written to explaining the reasons for this and what to do if they wish to appeal the decision.

3.5. The Primary Care Commissioning Committee is asked to approve the recommended option of agreeing to the smaller area reduction.

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Appendix 2: Information on Practices within affected wards

Overall Opening hours Reported Experience Opening Making an Capacity NACS (%good or hours (% appointment Organisation Name Code List Size very good) satisfied) (% satisfied) CQC Rating Monday – Friday Cloister Road Surgery E85680 11058 84% 61% 63% 08:00 - 18:00 Good Monday – Friday 5000 08:00 – 18:30 additional Saturday 9am – 1pm patients with existing capacity. Premises capacity for 10,000 CQC have not additional inspected this patients. Park Royal Medical Practice E84645 6947 83% 81% 80% service yet Mon-Wed, Fri -09:00 - 12:00 3000 Western Avenue Surgery - 14:00 - 18:30 additional Ealing E85630 3043 65.40% 64.30% 73.30% Thursday- 09:00 - 12:00 Good patients Mon-Tues, Thurs- Fri -09:30 - 1500 18:30 Additional The Westway Surgery E85005 3398 77.60% 66.60% 71.90% Wednesday -09:30 - 13:30 Good patients

these are scores in the worst 25% of all scores nationally; these are scores that are in the middle 50% of scores nationally; and these are scores that are in the best 25% of scores nationally.

Map 1 : Cloister Road Surgery Patient Distribution and current practice area

Map Index

Map Index Code Name Address 1 Address 2 Address 3 Postcode 1 E84665001 Greenhill Park Medical Centre Greenhill Park NW10 9AR 2 E84006 The Law Medical Group Practice 6 Leigham Court Road 9-11 Wrottesley Road Willesden NW10 5UY 3 E84006001 The Law Medical Group 124 Harrow Road HA9 6QQ 4 E84011 St Andrews Medical Centre Greenhill Park Medical Centre Greenhill Park Harlesden NW10 9AR 5 E84013 Church End Medical Centre Church End Medical Centre 66 Mayo Road Church End Estate NW10 9HP 6 E84017 Sudbury & Alperton Medical Centre 267 Ealing Road HA0 1EZ 7 E84021 The Willesden Medical Centre The Medical Centre 144-150 High Road Willesden NW10 2PT 8 E84026 Buckingham Road Surgery 2&4 Buckingham Road NW10 4RR 9 E84028 The Stonebridge Practice Hillside Primary Care Centre 150 Hilltop Avenue Harlesden NW10 8RY 10 E84029 Harness Harlesden Practice Hillside Primary CC 150 Hilltop Avenue Harlesden NW10 8RY 11 E84030 Aksyr Medical Practice Hillside Primary CC 150 Hilltop Avenue Harlesden NW10 8RY 12 E84051 Stanley Corner Medical Centre The Stanley Corner Med CT 1-3 Stanley Avenue HA0 4JF 13 E84066 Hazeldene Medical Centre 1B Wyld Way HA9 6PW 14 E84074 Freuchen Medical Centre Freuchen Medical Centre 190 High Street Harlesden NW10 4ST 15 E84080 Staverton Surgery Staverton Medical Centre 51 Staverton Road NW2 5HA 16 E84624 Park Road Surgery 26a Park Road NW10 8TA 17 E84637 Hilltop Medical Practice Hillside Primary CC 150 Hilltop Avenue Harlesden NW10 8RY 18 E84638 Alperton Medical Centre Alperton Medical Centre 32 Stanley Avenue HA0 4JB 19 E84645 Park Royal Medical Practice Health & Well-Being Hub Central Middlesex Hospital Acton Lane NW10 7NS 20 E84669 The Eagle Eye 26 Eagle Road HA0 4SH 21 E84705 Chamberlayne Road Surgery 124 Chamberlayne Road Kensal Rise NW10 3JP 22 Y00206 Burnley Practice First Floor,Willesden Centre Robson Avenue Willesden NW10 3RY 23 E84006002 Buckingham Road Surgery 2-4 Buckingham Road NW10 4RR 24 E84066001 The Eagle Eye 26 Eagle Road HA0 4SH 25 E84066003 Chamberlayne Road Surgery 124 Chamberlayne Road NW10 3JP 26 E84656 Roundwood Park Medical Centre Willesden Centre Hlth & Care Robson Avenue NW10 3RY 27 E85677 The Horn Lane Surgery 156 Horn Lane W3 6PH 28 E85680 Cloister Road Surgery Cloister Road Surgery 41-43 Cloister Road Acton W3 0DF 29 E85120001 Argyle Hanwell 14 Cuckoo Lane Ealing W7 3EY 30 E85013 Hanwell Health Centre (Stewart) Hanwell Health Centre 20 Church Road Hanwell W7 1DR 31 E85014 Northfields Surgery Northfields Surgery 61 Northfield Avenue Ealing W13 9QP 32 E85019 Crown Street Surgery 2 Lombard Court Crown Street Acton W3 8SA 33 E85026 Gordon House Surgery Mattock Lane Health Centre 78 Mattock Lane West Ealing W13 9NZ 34 E85028 Hillcrest Surgery Hillcrest Surgery 337 Uxbridge Road Acton W3 9RA 35 E85034 Grosvenor House Surgery Grosvenor House 147 The Broadway West Ealing W13 9BE 36 E85041 Hanwell Health Centre (Naish) Hanwell Health Centre 20 Church Road Hanwell W7 1DR 37 E85050 Greenford Road Medical Centre 591 Greenford Road UB6 8QH 38 E85051 Greenford Avenue Fhp Greenford Ave Medical Centre 322 Greenford Avenue Hanwell W7 3AH 39 E85054 Hillview Surgery 179 Bilton Road Perivale UB6 7HQ 40 E85057 Queens Walk Practice Queens Walk Practice 6 Queens Walk Ealing W5 1TP 41 E85066 The Bedford Park Surgery The Bedford Park Surgery 55 South Parade Bedford Park W4 5LH 42 E85069 Oldfield Family Practice Oldfield Family Practice 285 Greenford Road UB6 8RA 43 E85075 Chiswick Family Practice 89 Southfield Road Chiswick W4 1BB 44 E85088 Elmbank Surgery 438 Greenford Avenue W7 3DD 45 E85091 Brunswick Road Medical Centre Brunswick Road Medical Centre 75 Brunswick Road Ealing W5 1AQ 46 E85099 The Avenue Surgery 102 The Avenue W13 8LA 47 E85107 The Mill Hill Surgery The Mill Hill Surgery 111 Avenue Road Acton W3 8QH 48 E85109 The Acton Health Centre The Acton Health Centre 35/61 Church Road Acton W3 8QE 49 E85111 Perivale Medical Clinic 2-4 Conway Crescent Perivale UB6 8HX 50 E85116 The Cuckoo Lane Practice 1st Floor 20 Church Road Hanwell W7 1DR 51 E85120 The Argyle Surgery The Argyle Surgery 128 Argyle Road West Ealing W13 8ER 52 E85122 The Florence Road Surgery The Florence Road Surgery 26 Florence Road Ealing W5 3TX 53 E85122002 Bramley Road Surgery 2 Bramley Road W5 4SS 54 E85123 The Corfton Road Surgery 10 Corfton Road W5 2HS 55 E85130 Chiswick Family Practice Chiswick Family Practice 89 Southfield Road Chiswick W4 1BB 56 E85617 Acton Town Medical Centre Acton Town Medical Centre 122 Gunnersbury Lane Acton W3 9BA 57 E85628 Elthorne Park Surgery Elthorne Park Surgery 106 Elthorne Park Road Hanwell W7 2JJ 58 E85630 Western Avenue Surgery Western Avenue Surgery 56 Western Avenue Acton W3 7TY 59 E85635 The Vale Surgery 97 The Vale W3 7RG 60 E85640 The Churchfield Road Surgery 64 Churchfield Road W3 6DL 61 E85657 Ealing Park Health Centre Ealing Park Health Centre 195a South Ealing Road Ealing W5 4RH 62 E85687 Acton Lane Medical Centre 253 Acton Lane W4 5DG 63 E85694 The Boileau Road Surgery Boileau Road Surgery 104 Boileau Road Ealing W5 3AJ 64 E85714 The Pitshanger Lane Surgery 209 Pitshanger Lane W5 1RQ 65 E85726 Mattock Lane Health Centre Mattock Lane Health Centre 78 Mattock Lane West Ealing W13 9NZ 66 E85740 The Lynwood Surgery 9 Lynwood Road W5 1JQ 67 E85658 Holly Road Medical Centre Holly Road Medical Centre 2A Holly Road Chiswick W4 1NU 68 E85030 Chiswick Health Practice Chiswick Health Centre Fishers Lane Chiswick W4 1RX 69 E85040 West4 GPs The Chiswick Health Centre Fishers Lane Chiswick W4 1RX 70 E85625 Chiswick Family Drs Practice Chiswick Health Centre Fishers Lane Chiswick W4 1RX 71 E85681001 The Jersey Practice Jersey Practice 5 William Close Windmill Park UB2 4UP 72 E85683 Glebe Street Surgery 1 Glebe Street W4 2BD 73 E85659 Dr RK Kukar, Parkview Centre for H&W Dr Kukar, Parkview Cfh&W 56 Bloemfontein Road W12 7FG 74 E85005 The Surgery, Dr Dasgupta & Partners The Surgery 13 Westway Shepherds Bush W12 0PT 75 E85016 Richford Gate Medical Centre Richford Gate Medical Practice Richford Gate P.C.C. Richford Street W6 7HY 76 E85020 Brook Green Medical Centre Bute Gardens W6 7EG 77 E85032 Ashchurch Surgery The Ashchurch Surgery 134 Askew Road Shepherds Bush W12 9BP 78 E85042 The New Surgery The New Surgery 143a Uxbridge Road Shepherds Bush W12 9RD Dr Canisius & Dr Hasan, Parkview 79 E85048 Cfh&W 56 Cranston Court Bloemfontein Road W12 7FG 80 E85055 The Bush Doctors The Bush Doctors 16-17 West 12 Shopp Ctr Shepherds Bush W12 8PP 81 E85074 Brook Green Surgery 15 Brook Green W6 7BL 82 E85077 Shepherds Bush Medical Centre 336 Uxbridge Road W12 7LS 83 E85125 Sterndale Surgery Sterndale Surgery 74a Sterndale Road West Kensington W14 0HX Dr Uppal & Partn, Parkview Centre for 84 E85624 H&W Dr Uppal, Parkview Cfh&W 56 Bloemfontein Road W12 7FG 85 E85636 Park Medical Centre Inver Court Invermead Close W6 0QG 86 E85748 The Medical Centre, Dr Kukar The Medical Centre 13 Ollgar Close Uxbridge Road W12 0NF Hammersmith & Fulham Centres for 87 Y02589 Health Hammersmith Hospital DU Cane Road Hammersmith W12 0HS 88 Y02906 Canberra Old Oak Surgery Parkview Cfh, Cranston Court 56 Bloemfontein Road W12 7FG 89 Y02906001 The Old Oak Surgery 118 Old Oak Road Acton W3 7HG 90 Y01011 Barlby Surgery St Charles Centre Exmoor Street W10 6DZ 91 Y04510 Barlby Surgery (Walk in Service) St Charles Centre for Health & Wellbeing Exmoor Street W10 6DZ 92 E87003 North Kensington Medical Centre North Kensington Med Centre St.Quintin Avenue W10 6NX 93 E87733 The Exmoor Surgery Exmoor Surgery Exmoor Street W10 6DZ 94 Y00507 St. Quintin Health Centre St.Quintin Avenue W10 6NX 95 Y03077 St Charles Ucc Centre WIC St Charles Hospital Exmoor Street W10 6DZ

Map 2: Combined Distribution of registered patients of affected practices

Map 3: Time in minutes to each site by foot

Cloister Road

Alternative Practices

Map 4: Time in minutes to each site by Public Transport

Cloister Road

Alternative Practices

Map 5: Catchment area Coverage

Orange outlined area denotes existing catchment area for Cloister road and other supporting practices. Park Royal Medical Centre’s boundary is not available on the mapping software but covers the whole of the area being excluded by Cloister Road.

The blue outlined area shows area that will be covered by Park Royal Practice only, should Cloister Road’s boundary change be approved. Ward Demographic Profiles and Atlas https://data.london.gov.uk/dataset/ward-profiles-and-atlas

% English is (ID2010) - Average % children in Rate of All Rates of Population First Rank of (ID2010) % Public reception % children in Ambulance ambulance density % All Language of average of LSOAs in Transport year who year 6 who Incidents per call outs for (persons per Children % All Older no one in score (within worst 50% Accessibility Male life Female life are obese - are obese- 1,000 alcohol sq km) - aged 0-15 - people aged % BAME - household - London) - nationally - score - expectancy - expectancy - 2011/12 to 2011/12 to population - related Ward 2013 2015 65+ - 2015 2011 2011 2010* 2010 2014** 2009-13 2009-13 2013/14 2013/14 2014 illness - 2014 Ealing - Acton Central 8750 19.96 10.19 40.00 21.00 265 88.89 3.14 79.26 86.14 11.13 19.44 109.34 0.75 Ealing - East Acton 4523.3 19.84 8.52 50.10 22.40 241 100.00 3.98 79.10 85.64 11.13 26.10 115.16 0.74 Ealing - Hanger Hill 4787.9 19.10 13.96 43.10 23.80 495 44.44 3.67 82.23 87.77 7.11 18.40 87.79 0.33 Ealing - South Acton 9205.9 20.64 10.78 43.50 23.40 246 88.89 4.58 77.84 80.38 11.64 26.90 162.40 1.31 Ealing 6208.98082 20.84 11.42 51.00 20.80 305.565217 70.26 3.30 79.90 84.30 11.24 22.38 114.49 0.74 England 413.526315 18.92 17.83 14.60 4.40 n/a n/a n/a 79.10 83.00 9.41 19.07 n/a n/a

* The scores and ranks within London are given, with a rank of 1 denoting the most deprived out of a total of 627 wards in London. ** PTALs are a detailed and accurate measure of the accessibility of a point to the public transport network, taking into account walk access time and service availability. The method is essentially a way of measuring the density of the public transport network at any location within Greater London. Population weighted average scores were calculated using output area data. There are 9 levels of access, 0 to 9 (0 to 6b has 9 seperate levels). Each area was given an average score out of 8, where 8 is the highest level of accessibility. Open space was removed from the data as no population lives there.

Diversity Household Ethnic Group 5 groups - 2011 Census Religion - 2011 Census Language At least 1 person in of which household White Gypsy has English or Irish Asian or Black or Other Religion not as a main Names White Traveller Mixed Asian British Black British Other Christian Buddhist Hindu Jewish Muslim Sikh religions No religion stated language Acton Central 60% 0.30% 5% 15% 11% 9% 49% 2% 2% 0% 16% 1% 0% 21% 8% 79% East Acton 50% 0.75% 6% 17% 16% 11% 47% 1% 4% 0% 23% 1% 1% 16% 8% 78% Hanger Hill 57% 0.21% 5% 24% 5% 10% 46% 3% 5% 1% 15% 2% 1% 19% 8% 76% South Acton 57% 0.21% 5% 15% 16% 7% 49% 2% 2% 0% 19% 1% 0% 19% 8% 77% London 60% 0.17% 5% 18% 13% 3% 48% 1% 5% 2% 12% 2% 1% 21% 8% 87% England 85% 0.12% 2% 8% 3% 1% 59% 0% 2% 0% 5% 1% 0% 25% 7% 96%

Appendix 4

Equality and Health

Inequalities Analysis:

Standard Toolkit for CWHHE

CCGs

Briefing and associated templates based on NHS England Standard Requirements

Contents

Contents ...... 2 1 Equality and Health Inequalities Analysis ...... 3 1.1 Introduction ...... 3 1.2 Legal Duties ...... 3 1.3 Public Sector Equality Duty ...... 3 1.4 Health Inequalities Duties ...... 4 1.5 The Analysis Templates ...... 4 2 Equality Analysis ...... 5 3 Health Inequalities Analysis ...... 15 Annex A. Health Inequality Analysis - supporting questions ...... 16 Annex B. Equality Delivery Systems (EDS2) Goals and Outcomes………………… 12

1 Equality and Health Inequalities Analysis

1.1 Introduction These analysis templates have been developed to help you to think through the implications of your work on equality and on addressing health inequalities. They aim to help you take the right steps to make sure that the policy, commissioning and/or procedure you are developing has the best chance of reducing health inequalities and advancing equality of opportunity, whilst capturing the evidence that you have done so. This will support the CCG in meeting its separate legal duties on Equality and those on Health Inequalities. Section one contains the Equality Analysis and Section two the Health Inequalities Analysis.

Please note that all Equalities Templates must be reviewed and signed off by the Assistant Director of Equalities.

1.2 Legal Duties CCGs have two separate duties on Equality and on Health Inequalities. Whilst the purpose of both duties is to ensure that informed and conscious consideration is given by decision makers to assess needs in respect of the equality and inequality duties, it is important to appreciate that they are two distinct duties. This document is therefore divided into two parts; section one contains the Equality Analysis template and section two the Health Inequalities Analysis template.

1.3 Public Sector Equality Duty The public sector equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of 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.

These are sometimes referred to as the three aims of the general equality duty. The Act explains that having due regard for advancing equality involves: • Removing or minimising disadvantages suffered by people due to their protected characteristics.

• Taking steps to meet the needs of people from protected groups where these are different from the needs of other people.

• Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.

Should you have any queries please contact Dipen Rajyaguru, Assistant Director for Equalities & Patient Experience, [email protected]

1.4 Health Inequalities Duties The Health and Social Care Act 2012 established the first specific legal duties on CCGs to have regard to the need to reduce inequalities between patients in access to, and outcomes from, healthcare services and in securing that services are provided in an integrated way. These duties had legal effect from April 1st 2013.

The duties require that CCGs properly and seriously takes into account inequalities when making decisions or exercising functions, and has evidence of compliance with the duties, whilst also assessing how well commissioned providers have discharged their legal duties on health inequalities.

What is meant by “…have regard to…” in the duties? • Lawyers advise that “having regard to the need to reduce” means health inequalities must be properly and seriously taken into account when making decisions or exercising functions, including balancing that need against any countervailing factors.

• Part of having due regard includes accurate record keeping of how the need to reduce health inequalities have been taken into account.

1.5 The Analysis Templates Neither the public sector equality duty nor the Health Inequalities duties specify how CCGs should analyse the effect of their existing and new policies and practices on equality or on health inequalities. These templates are designed to help CCG staff members to assess the impact of policy and decision-making on equality and on addressing health inequalities and to keep records of doing so. There are and will be overlaps between the two templates and the evidence gathered for each.

The process of using the templates and working through the questions is as important as the outcome. The process is an opportunity to evaluate your evidence base for each question and involve stakeholders who can be involved in the discussion. If the evidence is not readily available or gaps are found, a proactive approach may be needed. Finally, record keeping should take place as a matter of course.

Section 2: Equality Analysis Please complete the template by following the instructions in each box.

Section 3: Health Inequalities Analysis Please complete the template by applying each question to your work, referring to the best available evidence. We strongly advise that you use and work though the supporting questions in Annex A.

Should you have any queries please contact Dipen Rajyaguru, Assistant Director for Equalities & Patient Experience, [email protected]

2 Equality Analysis

Title: Cloister Road Surgery Catchment Area reduction application

What are the intended outcomes of this work? Include outline of objectives and function aims

The Cloister Road Surgery is a two-partner GMS practice located in East Acton (Dr Dhall and Dr Sukumara). In line with the NHS England Primary Care Policy and Guidance Manual (PGM) the practice submitted an application to reduce their practice area (appendix 1).

The proposed reduction is shown below.

Note:the green shaded area represents the area the practice wish to exclude..

The reasons for the application to reduce their boundary are set out by the practice in their application and are summed up as follows;

 The practice reports capacity problems in light of 2 failed applications for premises extensions.  Space at the practice premises is limited and the practice has been significant list size growth in the last 5 years. There are number of new

developments within their proposed practice area and this area reduction will allow the practice to better serve these populations.

The maps at appendix 2 shows the distribution of patients registered with Cloister Road Surgery and the position of the surrounding practices. The excluded area falls within the East Acton Ward of Ealing, which borders Brent CCG area. Please outline which Equality Delivery System (EDS2) Goals/Outcomes this work relates to? See Annex B for EDS2 Goals and Outcomes 1.1 Services are commissioned, procured, designed and delivered to meet the health needs of local communities 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed 2.1 People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds

Who will be affected by this work? e.g. staff, patients, service users, partner organisations etc.

Patients - Patients living in the excluded area would no longer be able to register at The Cloister Road Surgery. The practice current boundary predominantly falls within 4 wards, East Acton, Acton Central, Hanger Lane and South Acton. The excluded area falls within East Acton ward only. The wards’ demographic profiles and comparative information between the four wards can be found at appendix 3.

Patients that currently fall within the practice’s area but do not fall within the new area would continue to stay registered with the practice. The practice would also continue to register children, dependent family members and carers of registered patient who live within this area.

Other local practices are likely to also be affected by reductions. The practices most likely to be affected are: Park Royal Medical Practice (Brent) Westway Surgery (H&F) Western Avenue Surgery

Both CCGs and the local practices have been engaged with about these changes.. Brent commissioners have informed that Park Royal is actively growing their list and would not object to the change.

6 evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on page 9 of this template.

Commissioners have looked at: Quality and Capacity of practices affected by reduction. This included CQC ratings and patient experience. Patient distribution analysis for The Cloister Road Surgery and other local practices. Catchment area coverage. Demographic profiling and Census data for the affected wards - https://data.london.gov.uk/dataset/ward-profiles-and-atlas

Age Consider and detail age related evidence. This can include safeguarding, consent and welfare issues.

The practice will need to provide assurance that they are continuing to maintain the care of registered patients within the existing catchment area and continue to register dependents of registered patients.

The comparative demographic information at appendix 3 demonstrates that the excluded wards have a similar age profile to the remaining practice area. East Acton, have fewer residents aged over 65 than the Ealing average and the other wards.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018 that is fully compliant with all accessibility standards for health facilities. This is accessible via public transport.

Patients living in East Acton may have to travel further to access Primary Care Services. Two of the local practices located in the south of the excluded area, Westway Surgery and Western Avenue Surgery, have lower than expected patient satisfaction rating for access, which may make it more difficult for patients in this area to access primary medical services.

There is no care home located in the excluded area.

Disability Consider and detail disability related evidence. This can include attitudinal, physical and social barriers as well as mental health/ learning disabilities.

The numbers of affected patients with disabilities is not known.

There is a section

Patients living in East Acton may have to travel further to access Primary Care

Services. The maps at appendix 2 demonstrate that the majority of patients would still have less than a 5-20 minute journey to a GP practice.

All practices are responsible for ensuring that they are regularly assessing their compliance with DDA requirements and making appropriate and reasonable adjustments as necessary. Gender reassignment (including transgender) Consider and detail evidence on transgender people. This can include issues such as privacy of data and harassment.

There is no data available on number of transgender people in each ward.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018, with a range of male and female GPs to choose from.

Marriage and civil partnership Consider and detail evidence on marriage and civil partnership. This can include working arrangements, part-time working, caring responsibilities.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018. This practice offers opening hours outside normal working hours.

Two of the local practices located in the south of the excluded area, Westway Surgery and Western Avenue Surgery, have lower than expected patient satisfaction rating for access, which may make it more difficult for patients in this area to access primary medical services. Pregnancy and maternity Consider and detail evidence on pregnancy and maternity. This can include working arrangements, part-time working, caring responsibilities.

All alternative practices offers similar maternity services.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018. This practice offers opening hours outside normal working hours.

Two of the local practices located in the south of the excluded area, Westway

Surgery and Western Avenue Surgery, have lower than expected patient satisfaction rating for access, which may make it more difficult for patients in this area to access primary medical services. Race Consider and detail race related evidence. This can include information on difference ethnic groups, Roma gypsies, Irish travellers, nationalities, cultures, and language barriers.

The ethnicity and language profile of the affected wards can be found in appendix 3. East Acton has a high BAME population compared to the other wards, particularly people identifying as Black or Black British.

The percentage of Irish Travellers and White Gypsy’s in East Acton is higher than the other wards and the London average.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018. This is accessible via public transport and offers a range of GPs and extended opening hours. This practice is actively growing their list.

Two of the local practices located in the south of the excluded area, Westway Surgery and Western Avenue Surgery, have lower than expected patient satisfaction rating for access, which may make it more difficult for patients in this area to access primary medical services. Religion or belief Consider and detail evidence on people with different religions, beliefs or no belief. This can include consent and end of life issues

The profiles in appendix 3 demonstrate that East Acton have a high number of Muslim residents compared to the other wards. The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018 that is fully compliant with all accessibility standards for health facilities. This is accessible via public transport.

Two of the local practices located in the south of the excluded area, Westway Surgery and Western Avenue Surgery, have lower than expected patients satisfaction rating for access, which may make it more difficult for patients in this area to access primary medical services. Sex Consider and detail evidence on men and women. This could include access to services and employment.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018, with a range of male and female GPs to choose from.

Sexual orientation Consider and detail evidence on heterosexual people as well as lesbian, gay and bisexual people. This could include access to services and employment, attitudinal and social barriers. There is no information available on sexual orientation in the ward profiles.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018, with a range of male and female GPs to choose from.

Two of the local practices located in the south of the excluded area, Westway Surgery and Western Avenue Surgery, have lower than expected patient satisfaction rating for access, which may make it more difficult for patients in this area to access primary medical services. Carers Consider and detail evidence on part-time working, shift-patterns, general caring responsibilities.

The practice will be required to continue the registration of dependents and carers of those patients registered at The Cloister Road surgery. That applies to the patients residing in the two wards being proposed in the reduction. Other identified groups Consider and detail evidence on groups experiencing disadvantage and barriers to access and outcomes. This can include different socio- economic groups, geographical area inequality, income, resident status (migrants, asylum seekers).

The profiles in appendix 3 demonstrate East Acton ward is a higher rate of deprivation compared to the rest of Ealing and the other wards.

Engagement and involvement

How have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available?

The practice has engaged with their PPG on their proposal, who are supportive of the change. Their engagement is detailed in the application found at appendix 1. How have you engaged stakeholders in testing the policy or programme proposals? The practice has engaged with their PPG on their proposal, who are supportive of the change. Their engagement is detailed in the application found at appendix 1.

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: As above.

Summary of Analysis

Patients living in the excluded area would no longer be able to register at Cloister Road Surgery. Part of the East Acton ward will be excluded from the practice’s catchment area.

The above analysis demonstrates that East Acton has higher BAME population, particularly people identifying as Black or Black British, higher number of Irish Travellers or White Gypsies and higher levels of deprivation, than the other wards currently covered by the practice.

The access maps at appendix 2 demonstrate that patients in the excluded area will still have no more than 5-30 minute travelling distance to their nearest GP practice, which is equivalent to the current access. The distribution map at appendix 2, map 2, demonstrates that the majority of the population in the excluded area are already registered at alternative practices.

The excluded area is covered by Park Royal practice, based in Central Middlesex hospital, a flagship health centre built in 2018, with a range of male and female GPs to choose from and extended opening hours. This practice is actively growing their list. However, The catchment area maps (map 5) in appendix 2 demonstrate that for a section of the excluded area, residents would only have one choice of local practice.

Registered patients who currently reside within the practice’s current area but do not reside within the new area would continue to stay registered with the practice. The practice would also continue to register children, dependent family members and carers of registered patient who live within this area.

Eliminate discrimination, harassment and victimisation Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation).

No identified impact Advance equality of opportunity Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation).

No identified impact

Promote good relations between groups Where there is evidence, address each protected characteristic (age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sexual orientation).

No identified impact

Evidence based decision-making

Please give an outline of what you are going to do, based on the gaps, challenges and opportunities you have identified in the summary of analysis section. This might include action(s) to eliminate discrimination issues, partnership working with stakeholders and data gaps that need to be addressed through further consultation or research.

Cloister Road Surgery has reported significant difficulties with maintaining high standards with the limitation of their current premises and the current rate of growth. Allowing the practice to reduce the area the cover will allow them to stabilise this growth and better serve their current patients, within the wards they cover, which includes the majority of East Acton ward.

The practice will be required to continue to register children, dependent family members and carers of registered patients who live within the excluded area.

The excluded area is served by the other practices and the majority of the population of those wards are already accessing GP services from those practices (demonstrated by the distribution map -map 2- in appendix 2). However, a section patients would be left with only one local practice who they can register with, which would reduce choice for patients in this area.

Residents in the south of the excluded area may find it more difficult to access primary care services as patient satisfaction with practices covering this area are than expected standards. Therefore, the practice will be requested to keep this area included with their boundary. The proposed excluded area is outlined below:

How will you share the findings of the Equality analysis? This can include corporate governance, other directorates, partner organisations and the public.

This will be shared with the Ealing Primary Care Committee in Public.

3 Health Inequalities Analysis

Evidence 1. What evidence have you considered to determine what health inequalities exist in relation to your work? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include local and national research, surveys, reports, research interviews, focus groups, pilot activity evaluations or other Equality Analyses. If there are gaps in evidence, state what you will do to mitigate them in the Evidence based decision making section on the last page of this template.

Commissioners have looked at: Quality and Capacity audit of affected practices. This included CQC ratings and access arrangements. Patient distribution analysis for Cloister Road and other local practices. Demographic and public health data for the affected wards - https://data.london.gov.uk/dataset/ward-profiles-and-atlas Impact 2. What is the potential impact of your work on health inequalities? Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to?

Patients living in the excluded area would no longer be able to register at Cloister Road Surgery. Part of the East Acton Ward is being excluded from the practice’s boundary area.

The demographic information in appendix 2 demonstrates that East Acton has higher deprivation compared to London and Ealing averages. The health indicators monitored by the Greater London Authority Ward Profiles and Atlas shown at appendix 3 show little significant difference between the affected wards, although it is noted that there is a higher percentage of children in year 6 who are obese in the East Acton Ward.

This population will continue to be served by surrounding practices, where the majority of the population of the excluded are are registered (appendix 2 patient distribution maps). Residents would have a choice of local practices.

The maps at appendix 1 demonstrate that patients residing over Hammersmith and Fulham will still have no more than a 5-15 minute walk to other local practices and no more than 5-10 minute journey time to reach a practice by local public transport.

There is some difference in patient reported satisfaction with overall experience and access at these practice and some practices have lower satisfaction than the national and Ealing averages, particularly those that service the south of the excluded area. Therefore it is proposed that this

Cloister Road Surgery has reported significant difficulties with maintaining high

15 standards with the limitation of their current premises and the current rate of growth. Allowing the practice to reduce the area the cover will allow them to stabilise this growth and better serve their current patients.

The quality and performance of primary care services will continue to be monitored through the primary care contact assurance processes, CQC assurance and the monitoring of patient registration issues and complaints information.

Where unwarranted variation in the quality and accessibility of primary care is identified we will work with those practices to ensure they have robust quality improvement plans

Monitor and Evaluation 4. How will you monitor and evaluate the effect of your work on health inequalities?

The quality and performance of primary care services will be monitored through the primary care contact assurance processes, CQC assurance and the monitoring of patient registration issues and complaints information.

For your records Name of person(s) who carried out these analyses: Rachel Claasen. Senior Primary Care Commissioning Manager, NWL Name of Sponsor Director:

Date analyses were completed: Review date:

Annex A. Health Inequality Analysis - supporting questions

The following questions have been developed to work as a prompt and help to guide you through each of the sections in the Health Inequalities analysis template. Please apply each question below to your work, referring to the best available evidence and record the outcome in the template above. We advise that you keep more extensive records and note where the evidence can be found for each answer.

These questions should also be asked throughout the planning and development of your work from initial development, through design and implementation, to evaluation of effectiveness.

1. What evidence have you considered to determine what health inequalities exist in relation to your work?  What health inequalities currently exist with regard to the health issue that your policy/procedure aims to address?

 What factors have created, maintained or increased health inequalities in access to, and outcomes from healthcare services?

 Who will be affected by your work and what are the demographics of the population affected?

 How is the health issue that your work is aiming to address distributed across different population groups and across different geographical locations?

2. What is the potential impact of your work on health inequalities?  How will your work affect health inequalities?

 Can you demonstrate through evidenced based consideration how the health outcomes, experience and access to health care services differ across the population group and in different geographical locations that your work applies to?

 Will the work address need across the social gradient or focus on specific groups?

 Will the policy/procedure have an unintended differential impact on different population groups and across different geographical locations?

 Would providing services in an integrated way reduce health inequalities?

3. How can you make sure that your work has the best chance of reducing health inequalities?  What can you do to make it more likely that the work reduces health inequalities?

 What have you done to mitigate against any failure to reduce health inequalities?

 Are there any dependencies or interdependencies that may impact on the work’s ability to address health inequalities? For example, are delivery partners sufficiently engaged in addressing health inequalities? Are there any resource implications that may affect the delivery?

 Will the work be equitably delivered to all population groups, with a scale and intensity proportionate to the level of disadvantage?

4. How will you monitor and evaluate the effect of your work on health inequalities?  How will you know whether your work has an impact on reducing health inequalities?

 Have you captured the evidence and recorded how the need to reduce health inequalities has been taken into account in the development of this work?

 Are there any gaps in the evidence that need to be addressed through further consultation or research?

 What will you do based on the gaps, challenges and opportunities you have identified in the evidence?

 Can you produce both whilst developing this work and at the end of the work, for assurance and risk mitigation, accessible records of all decisions and the decision making processes?

Definition of ‘population groups’ Health inequalities have been defined as “Differences in health status or in the distribution of health determinants between different population groups." [World Health Organisation Glossary of terms]

Health inequalities can therefore occur across a range of social and demographic indicators, including socio-economic status, occupation, geographical locations and the nine protected characteristics of the Equality Act 2010 (age, disability, ethnicity, gender reassignment, marriage and civil partnership, religion, pregnancy and maternity, sex (gender) and sexual orientation). The term ‘population groups’ is therefore used above to capture all such variables. The legal duties do not define specific groups - they are pertinent to any health inequalities on any dimension.

Annex B. EDS2 Goals and Outcomes

Goal Number Description of outcome Better health 1.1 Services are commissioned, procured, designed and outcomes delivered to meet the health needs of local communities 1.2 Individual people’s health needs are assessed and met in appropriate and effective ways 1.3 Transitions from one service to another, for people on care pathways, are made smoothly with everyone well-informed 1.4 When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse 1.5 Screening, vaccination and other health promotion services reach and benefit all local communities Improved patient 2.1 People, carers and communities can readily access access and hospital, community health or primary care services experience and should not be denied access on unreasonable grounds 2.2 People are informed and supported to be as involved as they wish to be in decisions about their care 2.3 People report positive experiences of the NHS 2.4 People’s complaints about services are handled respectfully and efficiently A representative and 3.1 Fair NHS recruitment and selection processes lead supported workforce to a more representative workforce at all levels 3.2 The NHS is committed to equal pay for work of equal value and expects employers to use equal pay audits to help fulfil their legal obligations 3.3 Training and development opportunities are taken up and positively evaluated by all staff 3.4 When at work, staff are free from abuse, harassment, bullying and violence from any source 3.5 Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives 3.6 Staff report positive experiences of their membership of the workforce Inclusive leadership 4.1 Boards and senior leaders routinely demonstrate their commitment to promoting equality within and beyond their organisations 4.2 Papers that come before the Board and other major Committees identify equality-related impacts including risks, and say how these risks are to be managed 4.3 Middle managers and other line managers support their staff to work in culturally competent ways within a work environment free from discrimination

More information on EDS2, including the EDS2 policy document, can be found at: http://www.england.nhs.uk/ourwork/gov/equality-hub/eds/

Brent Harrow Hillingdon BHH Clinical Commissioning Groups

Appendix 5

Title of scheme: Cloister Road Surgery Catchment Area Reduction Application Project Lead: Rachel Claasen NWL Primary Care Team

Brief description of scheme:

Cloister Road Surgery in Ealing CCG submitted an application to reduce their practice catchment area. The application was reviewed by a Task and Finish Group designated to review this and other similar applications received in Ealing by the Ealing Quality Sub Group.

The task and finish group identified that the practice had provided a robust application outlining their key growth concerns and limitations.

We are completing a QIA and EQHIA to assess wider quality considerations to be reviewed alongside the practices application before approval or rejection is reached.

Intended Outcomes (Quality Improvement, achieving equality, reducing health inequalities, reducing costs): Include outline of objectives and function aims

To be able to review quality impact to inform Ealing Primary Care Commissioning Committee regarding the decision to approve the practices catchment area reduction application.

Who/ how many people will be affected? (E.g. staff, patients, service users, partner organisations etc.) The area the practice wishes to reduce is sectioned into two main areas, East Action near to the Hammersmith and Fulham boarder and North Action towards the Brent boarder. If approval was granted to remove these two areas there would be patients who would previously have been able to register with the practice that would not be able to do so going forward.

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Review of the surrounding primary provision has indicated that there are a sufficient number of other local practices that patients can register with. All of whom provide good outcomes when measured against quality indicators. Existing registered patients and direct family members and carers of those patients already registered will continue to be able to register with the practice if the area reduction is agreed. We have identified three main local practices that may be affected by the reduction. One Hammersmith and Fulham practice and one Ealing CCG practice to the south east of the proposed reduced area and one Brent practice to the north). . What evidence has been considered to measure the impact of the scheme? (List the main sources of data, research and other sources of evidence reviewed to determine impact on patient safety and experience).

The practice application The overlap of other practice applications submitted Clear identification of practices that may be affected by the catchment reduction Map overlap showing catchment areas of local practices, reduction areas, patient distribution and ward information Capacity and performance data of those practices that have been considered as being most effected. Capitation figures- list size growth

Core Components for Quality Impact Assessment and Risk Identification Framework

Combined CWHHE and BHH CCGs QIA April 2017

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Component Impact assessment Information to support Score decision C x L (5x5 matrix) Mitigation identified Action required please score (this must be each completed for any element of negative impacts) the question Patient Safety patient safety? 0 Has mitigation of these factors been considered N/A within the proposed scheme? 0 Can this be mapped across to any of the CQC Y The two local H&F standard requirements? practices have been 0 rated as Good by the CQC. Park Royal in Brent is awaiting inspection Is there evidence of how the scheme will ensure y Local practices will essential standards can be achieved? continue to meet their 0 contractual requirements and provide assurance that essential services and standards are being met. Is there a capacity impact on partner organisations? Y The Brent practice It is proposed that north of the reduction the practice 6 area Park Royal. Park consider the Royal have informed removal of just the that that they are north Brent part of actively seeking to their catchment grow their list without area and continue the need for additional to cover the area

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Component Impact assessment Information to support Score decision C x L (5x5 matrix) Mitigation identified Action required please score (this must be each completed for any element of negative impacts) the question workforce. Park Royal near Hammersmith has informed that and Fulham there is also sufficient premises space to register significant additional patients with the need of minor premises modification. There are concerns regarding quality provision in the South East part of the reduction (towards the Hammersmith and Fulham border). Will this impact on the organisations duty to protect N Family members and children, young people and vulnerable adults? dependents of 0 existing registered patients will still be able to register with the Vale.

Overall score 9 Preventable Identification of any possible harm as a result of

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Component Impact assessment Information to support Score decision C x L (5x5 matrix) Mitigation identified Action required please score (this must be each completed for any element of negative impacts) the question harm planned changes through schemes. 0 Does it impact on systems and processes for N ensuring that the risk of healthcare acquired infections to patients is reduced? 0 Does it impact on systems and processes for N ensuring that the risk of medication errors is reduced? Overall score 0 Domain 2. How does the scheme affect or change patient 0 Patient experience? Experience / Have changes resulted from patient experience Y The practice have Patient & Lay feedback? indicated that the Feedback PPG have informed that they are dissatisfied with the length of time to obtain a GP appointment at the practice since the list growth. The area reduction would mean that the practice is able to stabilise its list

Combined CWHHE and BHH CCGs QIA April 2017

Brent Harrow Hillingdon BHH Clinical Commissioning Groups

Combined CWHHE and BHH CCGs QIA April 2017

Brent Harrow Hillingdon BHH Clinical Commissioning Groups

Component Impact assessment Information to support Score decision C x L (5x5 matrix) Mitigation identified Action required please score (this must be each completed for any element of negative impacts) the question patients in the excluded area will have an equivalent journey time to other local practices. Will the scheme impact on carers? Is there evidence of patient/lay representative Y Patients have been involvement/consultation on the scheme being engaged on the proposed? proposal through the PPG Has Healthwatch been involved in the process? N Is this change likely to have an impact on Potential positive complaints/PALs/FFT? (Response to national/local Y perceived Impact on surveys/complaints/PALS/incidents) patients registered at the practice. Patients in the north of the reduced area will however only have access to one local practice (Park Royal) covering the reduced catchment area. Is there a reputational risk to the organisation as a N result of the service change? Will the change generate media attention or N

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Component Impact assessment Information to support Score decision C x L (5x5 matrix) Mitigation identified Action required please score (this must be each completed for any element of negative impacts) the question interest? Overall score 9 Domain 3. Is there evidence that supports the proposed N/A Clinical change that delivers – innovation, meets NICE Effectiveness guidance, improve effectiveness of services? Is evidence based practice the basis for the change N/A – if so what evidence? Does the change ensure that care is delivered in N/A the most clinically appropriate setting? Does the scheme consider the impact on N/A readmission, avoidable emergency admissions and mortality rates? Overall score 0 Equality Does the planned scheme affect any particular Please use the CCG Equality and impacts group (protected characteristics) more than any Inequality Impact assessment other and how has this been mitigated? tool Workforce Does the scheme require redundancy, N redeployment or recruitment of staff? What is the impact on clinical workforce capability The practice have care and skills? informed that this reduction will help ensure that the practice can continue

Combined CWHHE and BHH CCGs QIA April 2017

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Component Impact assessment Information to support Score decision C x L (5x5 matrix) Mitigation identified Action required please score (this must be each completed for any element of negative impacts) the question to provide services safely. What is the impact on staff of the proposed As above scheme? Is there an additional training requirement as a N/A result of the proposed changes? Is there a greater skill and band mix – does this N impact on staffing ratios? Overall score 0

What degree of clinician engagement has taken The reduction is place? proposed by the GP 0 Clinical partners at the leadership practice. Is the scheme supported by lead clinicians? Y At what stage is there board level sign off for the Ealing Primary Care scheme? Commissioning Committee are 0 required to agree to this reduction Overall score 0 Domain 4. Does the scheme work to the strategic Yes the practice are required to 0 Sustainability commissioning direction of the CCG - for example continue to support the wider integrated care, admission avoidance, reducing sustainability direction delayed transfers of care, 7 day working, Strategic

Combined CWHHE and BHH CCGs QIA April 2017

Brent Harrow Hillingdon BHH Clinical Commissioning Groups

Does the scheme support the priorities identified in the Health and Wellbeing Strategy? Does it reduce/impact on variation in social care N provision? Compliance with the NHS Constitution n/a Overall score 0 Monitoring What arrangements do you have in place to ensure The quality and performance of 0 Arrangements that there is on-going monitoring of the changes in primary care services will commissioned services? continue to be monitored through What arrangement have you made for independent the primary care contact review and evaluation of the impact (review by assurance processes, CQC Quality and Safety Committee) assurance and the monitoring of patient registration issues and complaints information.

Where unwarranted variation in the quality and accessibility of primary care is identified we will work with those practices to ensure they have robust quality improvement plans Overall score 0

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Please consider how the outcome of this QIA will be shared.

Any score of 8 and above or one red score must be reviewed, for sign off/ approval by the Quality & Safety team. For information to the Quality and Risk Committee / Integrated Governance.

The QIA will need to be reviewed prior to submission to ensure that all the information is still relevant and that there are no material changes to the assessment and scores.

Name of person completing assessment:

Role: Signature: Date of assessment: Reviewed by:

Role: Signature: Date of Review:

Risk scoring = consequence x likelihood (C x L )

Likelihood

1 2 3 4 5

Consequence Almost Rare Unlikely Possible Likely certain

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5 5 10 15 20 25 Catastrophic 4 Major 4 8 12 16 20 3 Moderate 3 6 9 12 15 2 Minor 2 4 6 8 10 1 Negligible 1 2 3 4 5

Note: the above table can to be adapted to meet the needs of the individual trust.

For grading risk, the scores obtained from the risk matrix are assigned grades as follows 1 - 3 Low risk 4 - 6 Moderate risk 8 – 12 High risk 15 – 25 Extreme risk

Additional information to support completion can be drawn from the following documents:

1. NHS Choice Framework https://www.gov.uk/government/publications/the-nhs-choice-framework/the-nhs-choice-framework-what- choices-are-available-to-me-in-the-nhs 2. Shared Commitment to Quality (National Quality Board): https://www.england.nhs.uk/wp-content/uploads/2016/12/nqb-shared- commitment-frmwrk.pdf 3. Measuring the performance of local health systems (King’s Fund): https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/measuring-the-performance-of-local-health-systems-dh-review- kingsfund-oct15.pdf 4. Quality Improvement Made Simple: http://www.health.org.uk/sites/health/files/QualityImprovementMadeSimple.pdf 5. Health and Wellbeing Strategies (Local Authorities)

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6. National Patient Safety Agency (2008) A Risk Matrix for Risk Managers NPSA

Combined CWHHE and BHH CCGs QIA April 2017 E85019 Crown Street Surgery - Application to increase the practice catchment area

1. Practice profile and context

1.1. Crown Street Surgery is a multi-partner GMS practice. They have been rated as ‘Good’ by the CQC at the last inspection in April 2016.

1.2. The practice opening hours are as follows;

Day Opening Hours Surgery Hours Monday 08:00 - 12:30 13:30 - 08:30 - 12:00 15:30 - 17:30 18:00 Tuesday 08:00 - 12:30 13:30- 08:30 - 12:00 15:30 - 18:00- 20:00 20:00 Wednesday 08:00 - 12:30 13:30 - 08:30 - 12:00 15:30 - 17:30 18:00 Thursday 08:00 - 12:30 13:30- 08:30 - 12:00 15:30 - 18:00- 20:00 20:00 Friday 08:00 - 12:30 13:30 - 08:30 - 12:00 15:30 - 17:3 18:00 Saturday Closed Closed Sunday Closed Closed

1.3 The registered list size of the practice is 8672 as of January 2019. There has been a 6 % decrease from April 2013 to January 2019. This is compared to an Ealing average increase of 7% from 2013 (409,906) to 2018 (438,769).

Year List size April 2013 9203 April 2014 9032 April 2015 9098 April 2016 8902 April 2017 8761 April 2018 8708

2. Practice request to reduce boundary area

2.1. In line with the NHS England Primary Care Policy and Guidance Manual (PGM) the practice submitted an application (appendix 1) to change their practice area.

2.2. The proposed reduction is shown below.

1 | Page

Note: Inner red shaded area represents the practices current area. The outer black outline represents the practices proposed reduced catchment area.

2.3. The reasons for the application to reduce their boundary are set out by the practice in their application and are summed up as follows; • They wish to increase our list size • They received a large number of requests from people outside the practice boundary who wish to register with the practice.

3. Local Practices

3.1. There are several practices located in the expended area. A list of these practices along with their latest patient experience and CQC ratings is at appendix 2.

3.2. It is unlikely to have a significant impact on any one of the surrounding practices due to the number of patients likely to register from any particular area; however it may alleviate some of the reported pressures with capacity by practices in these wards.

3 Ealing Boundary Task and Finish Group

3.2 Over the past few months Ealing CCG have received several applications from practices applying to change their practice boundary areas. Ordinarily these applications would be considered independently, however, due to the number of requests submitted the Primary Care Committee has asked for a Task and Finish group to be set up so that these applications can be reviewed together to establish any interdependences and the overall impact on primary care provision and potential patient access implications.

2 | Page

3.3 The group was held on 11th February 2019. The group was provided with the practice applications, maps, capacity and performance data of those practices that have been considered as being most affected and ward level demographic data.

3.4 The group was asked to consider each application having regard to the interdependences between the application and taking into account the following:

a) The reasons why each practice is applying to change their practice area. b) What other options the practices have considered prior to the application being submitted. c) Practice completion of sufficient patient engagement d) The impact that the changed area would have on patient access to general medical services; e) Development of EQIAs, taking into account demographic information from affected wards and considering any disproportionate impact on patients with protected characteristics and health inequalities. f) Other practices’ boundaries and potential impact on neighbouring practices. Taking into consideration any known changes and quality and capacity information about those practices. g) The associated impact of the application not being approved.

3.5 For Crown Street Surgery the group recommends that the application to increase their boundary be approved subject to engagement with their PPG group.

The group took the following factors into account:

1. The practice has experienced a drop in list size over the past 5 years. 2. Several practices in the surrounding area are experiencing capacity issues. 3. It is noted that the practice has not yet engaged their patient participation group on the change. They would need to discuss the change with their group before the variation was made.

The Equality and Health Inequalities Analysis (appendix 4) and the Quality Impact Assessment (appendix 5) raised no further additional concerns about this area change.

4 Committee decision

3.3. Any changes to the practice area must be considered as a variation to the GMS contract. The PGM states that in considering an application, commissioners should have regard to other practices’ boundaries, patient access to other local services and in general other health service coverage within a location.

3.4. If the decision is made to approve the application, the practice contact variation will be drawn up to reflect the change. The practice will be asked to advertise the change on their website and practice leaflet.

3.5. If the decision is made to reject the application, the practice will be written to explaining the reasons for this and what to do if they wish to appeal the decision.

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3.6. The Primary Care Commissioning Committee is asked to approve the recommended option of agreeing to the area increase.

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18th December 2019

Dear NHS England

Application to Change the Practice Area

Please provide the information below to the Commissioner no less than 28 days before the requested contract variation.

1. Affix practice stamp: Crown Street Surgery 2 Lombard Court, Crown Street, Acton, W3 8SA

2. Explain the reasons for the We are keen to increase our list size and we have change of practice area: received a large number of requests from people in the area to register whom we are currently having to turn away or deregister should they move.

3. What options have you N/A considered, rejected or implemented to relieve the difficulties the practice have encountered about your current catchment area and, if any were implemented, what was your success in reducing or erasing such difficulties?

4. Have you had any discussions n/a with your registered patients (PPG) about your difficulties maintaining your current catchment area? If so, please summarise them, including whether registered patients thought the current catchment area of patients should or should not be reduced?

5. Have you spoken with other N/A contractors/ CCG in your practice area about the difficulties maintaining current catchment area and if so, please summarise the discussions including whether other contractors/ CCG thought the current catchment area of patients should or should not be change?

6. What reasonable support do N/A you consider the Primary Care Team would be able to offer, which would enable your current catchment area to patients to remain the same?

7. Please provide map of your Attached current catchment area (which includes the inner and outer catchment areas) and the proposed new catchment area (including the inner and outer catchment areas)

8. Provide any additional supporting evidence that may be relevant:

Appendix 4

Equality and Health

Inequalities Analysis:

Standard Toolkit for CWHHE

CCGs

Briefing and associated templates based on NHS England Standard Requirements

Contents

Contents ...... 2 1 Equality and Health Inequalities Analysis ...... 3 1.1 Introduction ...... 3 1.2 Legal Duties ...... 3 1.3 Public Sector Equality Duty ...... 3 1.4 Health Inequalities Duties ...... 4 1.5 The Analysis Templates ...... 4 2 Equality Analysis ...... 5 3 Health Inequalities Analysis ...... 11 Annex A. Health Inequality Analysis - supporting questions ...... 12 Annex B. Equality Delivery Systems (EDS2) Goals and Outcomes………………… 12