Cambridgeshire and Peterborough CCG Amended from NHS E documentation 17 th March 2017

1.1 Health Inequalities Duties The Health and Social Care Act 2012 established the first specific legal duties on NHS England 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 NHS England 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 CCGs 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.

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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 .

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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 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.

Answer To carry out this impact analysis for health inequalities the following sources of information have been considered: • End of Consultation Report ( CCG, March 2017) • Travel Time Estimates (Google Maps based on departure at 18.00 on 14 th March 2017) • Local Provider Transport Survey Data (HUC, Four Week Period; ~14 th February – 9th March 2017) • Local OOH Admissions Data (HUC, 19 th October – 19 th December 2016) • Local 111 Call Data (HUC, 2014-2017 – partly forecasted) • Migrant and Refugee Joint Strategic Needs Assessment for Cambridgeshire (2016) • Indices of Multiple Deprivation (2015) • R&P 2013 Mid-Year Estimates (Cambridgeshire City Council, 2013) • ONS Census Data (2011) • Travellers Joint Strategic Needs Assessment for Cambridgeshire (2010)

The catchment area of the Out of Hours (OOH) service is Cambridgeshire, excluding Peterborough, Fenland, Huntingdon and Ely as they have other relevant OOH services in their area. The population most affected by this change live within Cambridge City. Based on Cambridgeshire County Council estimates based on ONS Census data (2011), the population is 130,000. Please see Appendix Table 1.

Analysis of OOH attendance data (Appendix Table 2) shows that 50% of face-to-face consultations within the OOH Service are for patients who live in within Cambridge City .

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Appendix Table 3 shows the breakdown of 111 calls and face to face visits by practice around Cambridge City.

Age Appendix Figure 1 shows the distribution of face to face visits to Chesterton Out of Hours Centre by age. The largest age group attending face to face are for children aged 0-9 years old who make up 36% of face to face OOH consultations.

Income inequality The Centre for Cities report has analysed inequality in income and notes that Cambridge is the most unequal city in the country. Reference: http://www.centreforcities.org/publication/cities-outlook-2017/

Ethnicity Eastern Europeans The Migrant and Refugee Joint Strategic Needs Assessment for Cambridgeshire, 2016 notes that “Primary schools in the Cambridge City district area with the highest proportion of pupils who speak an A8 language are located in the Arbury, Kings Hedges and Chesterton areas – on the north side of Cambridge city.” Similarly, it notes that “Of the 10 secondary schools in Cambridgeshire with the highest percentages of children who primarily speak an EU A8 language at home, three are in Cambridge City, two in Fenland, two in South Cambridgeshire, two in Huntingdonshire and one in East Cambridgeshire. For example, North Cambs Academy ranks as the second highest schools with 9.3% of its pupil population primarily speaking an EU A8 language at home. The JSNA also notes that data from the school census shows higher numbers of people from Poland in Cambridge city, particularly in the north part of the city – Arbury and Kings Hedges.

Travelling Community The Traveller JSNA 2010 on Cambridge Insight Website acknowledges that it is extremely difficult to gather data on this population but notes that Gypsies and Travellers make up almost 1% of the population in Cambridgeshire and represent the largest ethnic minority in the county. In Cambridgeshire it is estimated that approximately 70% are Romany Gypsies, 20% are Irish Travellers and 10% are others including Scottish and Welsh Travellers and an increasing number of Eastern European Gypsies. There appears to be a difference in demographics across the county with a higher number of Irish Travellers in South Cambridgeshire and Eastern European Roma in Fenland.

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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?

Answer : • This is an “as is” transfer of the location of the service. Exactly the same service will be available to people before and after the proposed change. • This change concerns face to face consultations at a base. To be offered one of these all patients are first triaged by a clinician and assessed on whether they need urgent direct referral to Accident and Emergency. • The location of base is changing by 4 miles. • Any additional travel time is therefore unlikely to present a change in clinical risk. • The impact on inequalities in health outcome is assessed as likely to be neutral.

• Access time to the proposed new base will change and this is assessed in the next section.

3. Will this work produce any specific changes in inequalities in access?

Answer : • The proposal is to change the location but not the nature of the service which is offered. • Appendix Figure 2 shows that the most frequent location of residence for people coming to the Chesterton base for face to face review is CB4, followed by CB1. • Appendix Figure 3 shows that shows that there is a greater count of face to face attendees from the more deprived areas of the city. Given the established relationship between deprivation and health need this is not an unexpected finding. • Appendix Figure 4 shows that attendance rate increases with index of multiple deprivation of GP practice to a moderate degree.

The key question for changes in inequalities in access are

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1) How do people currently travel to face to face out of hours consultations at the Chesterton base? 2) What would be the impact on their travel if the base moved to the CUFHT site?

Current travel to Chesterton base for face to face consultations. Please see Appendix Table 4 which shows that in a recent survey no patient used public transport and 72% arrived by private car.

Impact on travel if the base moved to CUFHT Appendix Figure 6 shows that the five most deprived practices do have an increase in travel distance to the Out of Hours base of between a half (for the most deprived practice) and four miles. Appendix Figure 9 shows that the five most deprived practices do have an increase in travel times by car to the proposed new Out of Hours base. This increase is between 2 minutes (for the most deprived practice) and 19 minutes.

The conclusion is that people registered with the most deprived practices will have further to travel for a face to face out of hours consultation. However they are likely to be making this journey by car and the absolute distances and time increase is small. For the most deprived practice the increase in time and distance is negligible (half a mile and 2 minutes car travel time).

Impact on Travellers As part of the consultation the Cambridgeshire County Council Traveller Health Team has been contacted. They note that: “Change is easier for some people than others. The ease of access is valuable at the current location, parking is an important factor. Giving people permission to go to Addenbrookes for minor things could be confusing given recent messages about avoiding using A&E, even though it is different departments, the difference might not be clear to people.” (End of Consultation Report Appendix C).

4. Will this work produce any specific changes in inequalities in health outcome?

Answer: This proposal is about changes in location, not in services and will not produce changes in outcome. See note under (2) above. • This is an “as is” transfer of the location of the service. Exactly the same service will be available to people before and after the proposed change. • This change concerns face to face consultations at a base. To be offered one of these all patients are first triaged by a clinician and assessed on whether they need urgent direct referral to Accident and Emergency.

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• The location of base is changing by 4 miles. • Any additional travel time is therefore unlikely to present a change in clinical risk. • The impact on inequalities in health outcome is assessed as likely to be neutral.

5. How can you make sure that your work has the best chance of reducing health inequalities?

Answer:

• The vast majority of Out of Hours 111 contacts are completed by telephone and do not end up in a face to face consultation. These will be unaffected by the change in base. • Home visits from the GP out of hours service remain available when clinically indicated and will be unchanged. • The majority of people travelling for a face to face out of hours consultation do so by private car. • Discussions are ongoing with CUFHT about drop off and parking arrangements at the CUFHT site.

6. Would providing this service in an integrated way, either integrated within health service or integrated with social care, reduce inequalities in access to those services or reduce inequalities in the outcomes achieved?

Answer: • This service change allows for co-location of acute emergency care and out of hours care. It strengthens the links between them which may enable many of the patients who currently attend A&E with a condition better treated in primary care to be seen by a primary care clinician in future.

If yes please briefly state the plan for this integration:

• Further integration of primary care OOH and ED will be considered after a decision has been made about this location change.

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Risks 7. Are the risks to health inequalities clearly identified and part of your project risk register?

Yes

Monitor and Evaluation 8. How will you monitor and evaluate the effect of your work on health inequalities?

Through liaison with the provider of the Out of Hours service we will monitor the registered GP of people using the 111/Out of Hours service and whether the result is telephone advice, a home visit or a face to face base consultation. This will enable any significant changes in access to the service to be monitored.

For your records Name of person(s) who carried out these analyses: Ian Weller Head of Urgent and Emergency Care Name of Sponsor Director: Ruth Derrett, Director of Urgent and Emergency Care

Date analyses were completed: 16 th March 2017

Reviewer: Dr Fiona Head , Associate Director Clinical Outcomes and Population Health Strategy

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