Health and Equality Impact AssessmentHealth and Equality Impact Assessment Confidential Mott MacDonald, Spring Bank House, 33 Stamford Street, Altrincham, Cheshire WA14 1ES, United

Health and Equality Impact Assessment

Proposals to Change and Improve NHS Services

May 2012

Better Healthcare in Buckinghamshire

Confidential

307256 BPI BAS 2 D

DRAFT

May 2012

Health and Equality Impact Assessment

Proposals to Change and Improve NHS Services

May 2012

Better Healthcare in Buckinghamshire

Confidential

Mott MacDonald, Spring Bank House, 33 Stamford Street, Altrincham, Cheshire WA14 1ES, United Kingdom

T +44(0) 161 926 4000 F +44(0) 161 926 4100, W www.mottmac.com

Health and Equality Impact Assessment Confidential

Mott MacDonald, Spring Bank House, 33 Stamford Street, Altrincham, Cheshire WA14 1ES, United Kingdom

T +44(0) 161 926 4000 F +44(0) 161 926 4100, W www.mottmac.com

Revision Date Originator Checker Approver Description

A 13 April 2012 James Beard Sarah Reeves

Kerry Schofield Draft Report v.1

B 16 April 2012 Kerry Schofield Sarah Reeves Brian Niven Draft Report v.2

C 23 April 2012 Kerry Schofield Sarah Reeves Brian Niven Draft Report v.3

D 8th May 2012 Sarah Reeves Kerry Schofield Brian Niven Final Report

E 16th May 2012 Sarah Reeves Kerry Schofield Brian Niven Final Report

Issue and revision record

This document is issued for the party which commissioned it

and for specific purposes connected with the above-captioned

project only. It should not be relied upon by any other party or

used for any other purpose.

We accept no responsibility for the consequences of this

document being relied upon by any other party, or being used

for any other purpose, or containing any error or omission which

is due to an error or omission in data supplied to us by other

parties

This document contains confidential information and proprietary

intellectual property. It should not be shown to other parties

without consent from us and from the party which

commissioned it.

307256/BPI/BAS/2/D May 2012 DRAFT


Chapter Title Page

Executive Summary 1

1. Introduction 9

1.1 The Assessment ____________________________________________________________________ 9 1.2 The objective and scope of the Impact Assessment _________________________________________ 9 1.3 The purpose of this report _____________________________________________________________ 9 1.4 The structure of this report ___________________________________________________________ 10

2. Better Healthcare in Bucks Proposals 11

2.1 Background _______________________________________________________________________ 11 2.2 The Case for Change _______________________________________________________________ 11 2.3 BHiB proposals ____________________________________________________________________ 12

3. Impact assessment methodology 16

3.1 Background to impact assessments ____________________________________________________ 16 3.2 Approach to this assessment _________________________________________________________ 18 3.3 Assumptions and limitations __________________________________________________________ 19

4. Emergency care and urgent care 21

4.1 Services changes under review _______________________________________________________ 21 4.2 Health Impacts ____________________________________________________________________ 22 4.3 Equality impacts ___________________________________________________________________ 24

5. General medicine inpatient care 28


6. Elderly care 33


7. Breast services 36

7.1 Services changes under review _______________________________________________________ 36 7.2 Health impacts ____________________________________________________________________ 37 7.3 Equality groups‟ need for breast services ________________________________________________ 38

8. Vascular services 40


Content

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9. Overall impact of proposals 48

9.1 Potential positive impacts ____________________________________________________________ 48 9.2 Opportunities ______________________________________________________________________ 50 9.3 Potential negative impacts ___________________________________________________________ 52 9.4 Mitigations ________________________________________________________________________ 56

10. Conclusions and recommendations 59

10.1 Key findings – individual service areas __________________________________________________ 59 10.2 Key findings – overall BHiB programme _________________________________________________ 63 10.3 Recommendations _________________________________________________________________ 64 10.4 Concluding observations _____________________________________________________________ 65

Appendices 66

Appendix A. Distribution of populations with protected characteristics ____________________________________ 67 A.1. Young males ______________________________________________________________________ 67 A.2. Older people ______________________________________________________________________ 69 A.3. Females aged over 45 ______________________________________________________________ 71 A.4. Disabled people ___________________________________________________________________ 73 A.5. BAME groups _____________________________________________________________________ 75 A.6. Deprived communities ______________________________________________________________ 77 Appendix B. Option A for vascular services ________________________________________________________ 79 B.1. Option A _________________________________________________________________________ 79

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Background

In March 2012, Better Healthcare in Buckinghamshire (BHiB) commissioned Mott MacDonald to carry out

an independent Health and Equality Impact Assessment (HIA and EqIA) of proposals to reconfigure a

range of health services across Buckinghamshire.

The BHiB programme seeks to ensure that health services for the population of Buckinghamshire are safe

and sustainable for the future, and respond to the challenges and opportunities within the NHS going

forwards.

BHiB have identified four key aims for the programme. These are to develop health services which:

are high quality, with excellent results for patients;

are accessible, with care close to home for most people;

offer a good patient experience; and

can be sustained, despite future challenges.

In order to achieve these aims, a series of options were developed to ensure that services were fit for

purpose, ranging from a „do nothing‟ option to the development of a new hospital in the county.

After undergoing an appraisal process, a preferred option (Option 3) was identified by clinicians. This

option would reconfigure acute services in one network. The network would be between the two

Buckinghamshire acute hospitals of Wycombe Hospital and Stoke Mandeville Hospital, with links to

Wexham Park Hospital in Slough and, for vascular services, to the Oxford University Hospitals.

Reconfiguration proposals do not include changes to all services; planned care, day cases and outpatient

services will remain unchanged. Table 1.1 below outlines the services that will be impacted and the

proposed service changes at each of the two key hospital sites.

Table 1.1: Configuration of these five services under BHiB proposals (based on Option 3)

Service Stoke Mandeville Hospital (SMH) Wycombe Hospital(WH)

Emergency Care No change proposed to the Accident and Emergency Department (adult and children, including trauma and GP-led centre)

For those who currently attend the Emergency Medical centre (EMC) at Wycombe without having seen their GP or another clinician first, they will still be able to attend the new minor injury and illness service. GPs and the ambulance service will direct those requiring urgent hospital attention to the most appropriate A&E department (e.g. Stoke Mandeville or Wexham Park hospitals).

Day assessment unit for frail (usually) elderly people

General Medicine Inpatient Care

Proposal for emergency respiratory, gastroenterology, diabetes inpatient admissions to be centralised and admitted to Stoke Mandeville Hospital

Outpatient services will continue to be provided at Wycombe Hospital.

Creation of a step-down ward for those who no longer need acute hospital care at Wycombe Hospital.

Elderly Care Proposal for elderly admissions to be admitted to Stoke Mandeville Hospital

Day assessment unit: new service development for Wycombe Hospital. GPs will be able to refer into this service and obtain advice and support for patients to remain out of hospital

Executive Summary

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Breast Services Stoke Mandeville Hospital will not provide the initial assessment and first outpatient appointment services as these will be provided at the new Wycombe Centre. Follow up breast care and chemotherapy to remain at Stoke Mandeville

Proposal to centralise initial assessment and first outpatient appointments at Wycombe Hospital through the creation of one-stop clinics in a new specialist breast care unit. Follow up breast care and chemotherapy to remain at Wycombe Hospital

Specialist networked services (Vascular)

No change to current service profile Day surgery, diagnostics, outpatients and surgery to prevent strokes caused by carotid artery disease would remain unchanged. Vascular complex inpatient services and 24 hour emergency inpatient surgery (including abdominal aortic aneurysms) proposed for John Radcliffe Hospital in Oxfordshire to do

The Assessments

The objective of the HIA and EqIA is to identify the impacts (positive and negative) of the proposed

reconfiguration of these services across Buckinghamshire, considering the service areas and the changes

overall, with regard to the likely effects on:

health outcomes;

access to services; and

equality groups.

The output of the integrated HIA and EqIA is the production of a set of evidence-based findings and

recommendations that can be used by decision-makers to maximise the positive impacts and minimise any

negative impacts of the BHiB proposals.

Key findings – individual service areas

The table below sets out the key impacts by service area and also highlight which equality groups out of

the nine protected characteristics are most likely to experience impacts.1 The table focuses on those

equality groups which are expected to experience disproportionate impacts (that is, over and above

the population in general). Those for who differential effects are not expected are not included.

_________________________ 1 The nine protected characteristics (or equality under the Equality Act (2010): age; disability; gender reassignment; pregnancy and

maternity; race; religion; sex; sexual orientation; and marriage and civil partnership. The EqIA considered all of these in the screening exercise and then „screened in‟ those groups that are likely to have a higher propensity to experience certain conditions and, therefore, the services under review. This was done on a service-by-service basis. The role of an EqIA is to focus on those groups who are likely to experience different (i.e. type of impact) and disproportionate (i.e. to a greater extent) impacts – not groups who are likely to experience the same impacts as the general population or no impact at all.

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Table 1.2: BHiB – service specific impacts

Service Health impacts Equality impacts Mitigating actions identified by BHiB to date

Emergency Care Concentration of expertise at Stoke Mandeville will enable the hospital to offer the full range of complex emergency presentations and achieve better outcomes. Admissions will be appropriate with decreased lengths of stay and fewer onward specialist referrals.

Minor injuries/illness service to be developed at Wycombe Hospital.

Day assessment unit for frail (usually) elderly people.

Older people, BAME groups and deprived communities are the equality groups most susceptible to requiring emergency care service. It is expected, however, for the numbers experiencing these negative impacts to be very small because many patients (up to two thirds)2 will be able to receive treatment at the minor injury and illness service based at Wycombe. In addition some of the more serious injuries experienced by these groups will be treated at the trauma unit at Stoke Mandeville, which is the same as at present. This should help to offset disproportionate impacts.

Developing effective communications to ensure residents are clear about what is provided on which site and how to access services.

Ambulance protocols to convey emergency patients to the appropriate site.

Protocols to manage patient transfers between sites if required.

Partnership working between services to manage patients locally and avoid unnecessary presentations at A&E, e.g. SCAS and the adult community team working with the falls team to manage in the community patients who have fallen.

Ongoing review to ensure services remain responsive to patients from a range of minority backgrounds.

_________________________ 2 This assumption is based on analysis of the numbers of patients attending the Wycombe Emergency Medical Centre in 2010. See Consultation Document (16 January to 16 April

2012) Better Healthcare in Buckinghamshire p. 13.

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The proposals present an opportunity to provide sufficient consultant staffing and on-call cover. There will be increased continuity of care by sub-specialist teams. Patients with acute medical illness should get better access to a specialist in that field which will improve outcomes and recovery times.

For those acutely ill people requiring general medicine inpatient services, they will also have access to the full range of emergency, critical care and diagnostic services at Stoke Mandeville.

Older people, BAME groups, those with learning disabilities and mental health illnesses and deprived communities are the equality groups most susceptible to requiring general medicine and inpatient care.

Given the high density of older people and BAME groups around Wycombe Hospital these two equality groups will potentially experience disproportionate negative impacts. This is particularly the case for older people because they are high users of all of the sub-services included in „general medicine inpatient care.‟ Whilst the investment in more community-based care and the multi-disciplinary assessment centre (see row below) would help to mitigate the need for emergency admissions for older people, this group is still likely to experience the impacts of these service changes to a disproportionate extent when an admission is required.


Review of the Buckinghamshire transport infrastructure and the development of viable travel options including a community hub.

Robust protocols to manage patient transfers between sites if required.

Ensuring future investment in 24/7 community based services to enable non urgent patients to be managed closer to home.

Enabling GPs and SCAS direct access to clinicians to support decision-making.


Elderly Care The proposed service will build on work which is already underway locally to support the delivery of increased care in community settings and the reduction of hospital admissions. For those older people requiring elderly care inpatient services, they will also have access to the full range of emergency, critical care and diagnostic services at Stoke Mandeville. This will support the many elderly patients who have complex co-morbidities.

Older people are the key equality group to be affected by changes proposed in this service area. There could be some disproportionate adverse effects for the small number of older people who require acute care and who need to travel further in future to reach this. This will affect not only the patient themselves but also elderly spouses, friends or other relatives who want to visit the patient. The impact of these longer travelling times will, however, in part be minimised by the „step down‟ ward at Wycombe meaning that as soon as patients no longer require treatment they can be moved closer to home and their local community.

There are also likely to be disproportionate positive impacts for older people because (a) a multidisciplinary assessment centre will be developed at Wycombe, which is expected to serve mainly older people whose symptoms mean that they are described as frail; and (b) they will have access to more community and home-based care.







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Breast Services Developing a Centre of Excellence for Breast Services will offer the best quality of care, clinical outcomes and patient experience. Staff will benefit from the sharing of expertise amongst a specialised, multi-disciplinary breast team. Breast service patients will be able to access all the relevant specialists in one place at their first assessment.

Women over 50 are the key equality group who will be affected by these proposals. As far higher numbers of women over 50 live around Wycombe as compared to Stoke Mandeville, there are likely to be disproportionate positive effects for this equality groups as a whole. However, those women living by Stoke Mandeville who require breast assessment services in future will have to access other hospital sites.




Vascular services

The proposals achieve critical mass, which enables improved clinical quality. Specialisation by doctors will improve outcomes. 24/7 interventional radiology rotas will be implemented.

Older people, BAME groups, those with learning disabilities and mental health illnesses and deprived communities are the equality groups most susceptible to requiring vascular services. Given the high densities of older people and BAME groups in Buckinghamshire, there could be disproportionate negative effects for these groups as a result of these services moving to the John Radcliffe. It should be noted, however, that whilst these groups could potentially be disproportionately disadvantaged the numbers affected in any one equality group are likely to be very small given the overall volume of patients at Wycombe hospital that require complex vascular services (105).



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Key findings – overall BHiB programme

The positive impacts that have been identified during this assessment are:

Health and clinical outcomes will be improved through the centralisation of acute services onto

fewer sites. This will enable surgeons, physicians and units to deliver care appropriately and safely,

maintain and improve their expertise and provide 24/7 on-call cover.

Investment in more community care and provision of care closer to home will reduce the time and

inconvenience of travelling and a hospital admission. This is likely to deliver particular benefits to older

people and other equality groups including those from deprived communities and BAME groups.

Patients will experience better quality of care, accessing services and competent decision-makers

more quickly and benefiting from continuity of services from a specialist team.

There are also some key benefits for staff which include the creation of more sustainable, specialist

teams; shared learning and development of expertise; and improved practice arrangements and rotas

which could benefit both recruitment and retention.

The assessment has also identified some potential negative impacts. These are:

The new service configuration could lead to confusion amongst some patients about how to access

the healthcare that they need. This could lead to a proportion of walk in emergency cases presenting

at a Wycombe Hospital resulting in the need to transfer them to a more appropriate site. This would

delay treatment and could affect clinical outcomes. Uncertainty about where to present could be a

particular issue for some equality groups who are accustomed to the current system. It should be noted,

however, that a minor injuries and illness service and the GP out of hours service will be available in

Wycombe Hospital and in emergency cases patients are less likely to self-present and rather would be

transferred by ambulance, minimising this risk.

Whilst the proposals aim to centralise services and reduce fragmentation in care pathways, for some

services (general and elderly medicine) there could be impacts for patients given the split in service

delivery with acute medical care provided at Stoke Mandeville Hospital and rehabilitation and step down

care provided at Wycombe Hospital. This will require new working relationships to ensure that patients

are effectively managed. This could also lead to capacity challenges for community and voluntary

organisations which can play an important role in discharge.

Some patients will need to travel longer distances to access the care that they need in future. This

will particularly affect people living in the south of the county who will need to travel to Stoke Mandeville

(or in some cases Wexham Park) for acute inpatient services. Longer travelling times disproportionately

affect some equality groups, particularly older people, disabled people and those on low incomes who

find travelling long distances more of a challenge due to mobility, confidence or economic constraints. It

is worth noting though that these travel impacts will affect few numbers of patients per year for the

following reasons: (a) approximately 7,600 people who currently use Wycombe (3% of the annual

patient caseload) and 1,700 patients (0.3% of the patient caseload) who currently use Stoke Mandeville;

and (b) given the nature of the services moving to Stoke Mandeville (medical emergency services and

acute inpatient care) many of them will be transported by ambulance. The longer distances may affect

those patients waiting for an emergency ambulance response due to an increase in incident cycle time

which will reduce the time in which the ambulance will be available to others. The longer travelling

distances will also affect visitors,3 many of which could also fall into the equality groups identified as

vulnerable to these transport impacts.

_________________________ 3 NHS Buckinghamshire has commissioned a separate impact assessment to further consider the impacts on visitors.

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Short term capacity constraints at Stoke Mandeville hospital during transition whilst the services

undergo the proposed changes and capacity is increased at Stoke Mandeville hospital and in the

community. This could also lead to potential delays for ambulance crews at Stoke Mandeville hospital.

Successful implementation of the new system is reliant on the realignment of ward areas at Stoke

Mandeville and the effective functioning of and transfer to step-down facilities at Wycombe.

Finally, the proposed configuration for breast assessment services will limit the current choice

that women have between the two hospital sites at the Trust although other local service

providers are available.

Conclusions and recommendations

The assessment has identified several improvements measures which will help to maximise the benefits

outlined above and mitigate the potential negative consequences. It is recommended that these measures

are considered by NHS Buckinghamshire as BHiB is taken forward:

It will be essential to get implementation of the new configuration right. Close joint working will be

necessary between hospital specialist, GPs and other primary care professionals if reductions in

inpatient admissions are to be delivered. The implementation plan also needs to set out enabling

milestones; address future commissioning; ensure change management is transparent; and establish

robust monitoring procedures.

A communication strategy will be critical. The reconfiguration‟s success will be dependent on clarity

and understanding about the services on offer at each site. Allied to this it will be important to clearly

explain the rationale and expected outcomes behind the changes. There are particular opportunities to

target affected equality groups (notably older people, BAME communities; those from deprived

communities and those who have learning disabilities and mental health illnesses) through

communication activities, to ensure that any particular challenges they could face are addressed.

Entering discussions with local representative groups to understand the most appropriate

communication channels would be a sensible first step in this strategy.

Equally as important will be excellent communication between the hospitals themselves. This will

help mitigate transitional problems associated with transfer protocols and fragmented pathways of care.

Good cross-site working will also be necessary to deal with patients with complex co-morbidities.

Discharge protocols underpinned by proactive management of patients through the inpatient pathway

and integrated hospital/community working will need to be established as a priority.

The BHiB transport subgroup is already developing mitigation steps to help alleviate concerns

about longer travel distances. Key measures that should be considered include the provision of travel

information for patients and their families, in a variety of formats and distributed though various different

media; pedestrian way-finding to help both patients and relatives navigate unfamiliar sites; and travel

planning for staff and patient access. Attention may also need to be given to those on lower incomes

who face long public transport trips to visit relatives who have lengthy inpatient stays.

In terms of meeting the aims and objectives of the Equality Duty:

This assessment concludes that the proposed changes will not lead to any unlawful discrimination.

All of the population will have access to the same level of services meaning opportunities are equal

at the point of service receipt. However, as some potential disproportionate negative impacts have

been identified for some protected groups (due mostly to the impact of short-medium term confusion

about changes to the services and increased travel times), the proposals won‟t necessarily advance

equality of opportunity for all at the point of demand. However, the implementation of appropriate

mitigation actions, both those already planned by BHiB and the additional actions suggested within

this report, will largely address this issue and help to ensure that equality of opportunity is

maximised.

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In terms of fostering good relations, this aim has less relevance to the BHiB proposals. However, it is

possible that some slight benefits could be experienced through interaction with and experience of

new local communities when being treated at or visiting a different hospital. Any impacts are

expected to be marginal.

In summary, the findings of the assessment suggest that the reconfiguration proposals would have the

potential to bring considerable benefit to the population of Buckinghamshire in terms of improved health,

wellbeing and clinical outcomes. The realisation of these benefits would result in some trade offs,

particularly in terms of increases to the time people would need to spend travelling for hospital treatment.

However, these trade offs are relatively limited compared to the proposals‟ benefits. In addition, they would

also only be experienced by the small proportion of the population who require access to the services

under review.

Locally, BHiB is already undertaking work to address some of the impacts identified in this report.

Continuing with the development of the measures, together with implementing the additional

recommendations suggested in this report will assist in enhancing the effectiveness of the proposals but

also augment the positive impacts that are likely to accrue.

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1.1 The Assessment

In March 2012, Better Healthcare in Buckinghamshire (BHiB) commissioned Mott MacDonald to carry out

an independent Health and Equality Impact Assessment (HIA and EqIA) of proposals to reconfigure

services across Buckinghamshire. This report brings together, and builds on, the findings from existing

impact assessments which have been published on the BHiB website4.

The remit of the HIA and EqIA is to consider the positive and negative impacts that each proposal could

have on health outcomes, equality groups and deprived populations and access to services. The impact

assessment is also required to consider mitigation measures for any adverse consequences identified and

ways in which service proposals could be further improved to maximise the quality and equality of

outcomes for Buckinghamshire‟s population.

1.2 The objective and scope of the Impact Assessment

The objective of the HIA and EqIA is to identify the impacts (positive and negative) of the proposed

reconfiguration of services in Buckinghamshire, considering the service areas and the changes overall, with

regard to the likely effects on:

Health outcomes;

Access to services; and

Equality groups.

These aspects are considered with particular emphasis placed upon impacts on health inequalities and

equalities groups. Focus will also be placed on the impacts for those patients who would be

disproportionately affected (i.e. vulnerable groups) compared to effects on the whole of the

Buckinghamshire population.

The scope of this assessment covers:

The service changes proposed within the BHiB Programme;

The geographical boundary of Buckinghamshire; and

The likely impacts related to health outcomes and access, in particular for health inequalities and

equalities.

1.3 The purpose of this report

This is the final report of the independent HIA and EqIA. This report comments on the impacts associated

with BHiB under five discrete service areas:

Emergency care and urgent care;

General medicine inpatient care, including gastroenterology, diabetes, medicine for older people and

respiratory services;

Elderly care;

Breast services; and

Specialist „networked services‟: vascular services.

_________________________

4 See: http://www.buckspct.nhs.uk/bhib/

1. Introduction

http://www.buckspct.nhs.uk/bhib/

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The report considers each service area in isolation and examines the health, equality and wider impacts

that are likely to be experienced as a result of reconfiguration. For each service, the specific equality

groups and geographical areas that are likely to experience most impacts are also highlighted. In addition,

the report considers cross-cutting impacts and issues which are a feature for all five service areas. It makes

recommendations for actions that could be taken to mitigate any potential adverse impacts arising from

proposed changes to services identified by the impact assessment. Finally, the report also makes a

number of recommendations to BHiB as to how potential benefits of the changes can be maximised and

equality of outcomes improved and enhanced.

1.4 The structure of this report

The structure of this report attempts to reflect our approach and sets out each of the linkages that enable

us to provide a full perspective on the likely effects on equality groups of the proposed changes to health

care services.

Chapter 2 – BHiB proposals

Chapter 3 – Our approach

Chapter 4 – Emergency care

Chapter 5 – General medicine inpatient care

Chapter 6 – Elderly care

Chapter 7 – Breast services

Chapter 8 – Vascular services

Chapter 9 – Overall impact of proposals

Chapter 10 – Conclusions and recommendations

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2.1 Background

Launched in 2009, a regional review of the Buckinghamshire and Berkshire health system titled „Care for

the Future‟ identified that all of Buckinghamshire‟s hospitals had a role to play in the local NHS but that

changes needed to be made. It recommended that far more could be provided in the community, to help

patients avoid hospital admission, or to be discharged more quickly when they no longer need hospital

care. 5

In response to „Care for the Future‟ and to ensure that health services are able to continue to adapt to the

changing context of the NHS, in 2011, Buckinghamshire and Oxfordshire NHS Cluster established the

Better Healthcare in Buckinghamshire (BHiB) programme. This has been developed in partnership with

Buckinghamshire Healthcare NHS Trust and the developing Clinical Commissioning Groups.

2.2 The Case for Change

The BHiB programme seeks to ensure that health services for the population of Buckinghamshire are safe

and sustainable for the future, and respond to the challenges and opportunities within the changing NHS

context. Key drivers of this change include:

Responding to the rising demand on health services from an increased aging population. In particular,

long term conditions including heart disease, stroke, diabetes and asthma affect tens of thousands of

people in Buckinghamshire. The vast majority of patients with these conditions can be well cared for in

the community, if the right services are available;

Evidence shows that patients see better results and improved outcomes and survival rates if they are

treated in specialist centres of excellence, but these need specialist equipment and also a critical mass

of patients if clinicians are to maintain their skills. Nationally, such centres of excellence often work

together in networks across a region, to ensure that all patients have access to high quality care.

Successful networked services include cancer and critical care services and trauma and stroke services

are now being planned on a regional basis;

Ensuring that, where appropriate, services are developed to treat patients as close to home as possible;

either in the community or in the home. This reflects what patients say they want, and provides better

outcomes; and

There are two acute hospitals providing hospital services across Buckinghamshire: Stoke Mandeville

and Wycombe. At present some specialist services are provided at one hospital only, and some

specialist services at both hospitals. For some of these services, this duplication across both hospital

sites is unsustainable for quality, safety, staffing and efficiency reasons.

_________________________

5 Care For The Future: The developing vision of future healthcare for Berkshire and Buckinghamshire (August 2011) NHS Buckinghamshire and Oxfordshire Cluster and NHS Berkshire

2. Better Healthcare in Bucks Proposals

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BHiB have identified four key aims for the programme; to develop health services which:

Are high quality, with excellent results for patients;

Are accessible, with care close to home for most people;

Offer a good patient experience; and

Can be sustained, despite future challenges.

The Public Consultation Document6 provides further detail on the case for change. It should also be noted

that while Better Healthcare in Bucks is a programme of work to improve the way in which acute hospital

services are provided in Buckinghamshire, it should not be seen in isolation. In Buckinghamshire, as

elsewhere in the country, the NHS is striving to create health services which are better integrated, with no

artificial barriers between health and social care organisations or between hospital, primary and community

services and which put the patient at the heart, providing people with information to make decisions about

their own health and well being and their care.

2.3 BHiB proposals

The HIA and EqIA investigate the likely effects of implementing the BHiB proposals for the reconfiguration

of services across Buckinghamshire. This section defines those proposals and provides some background

to their development.

2.3.1 Developing the proposals

In response to the publication of the „Care for the Future‟ final report in 2011, clinical colleagues identified

seven potential options for how services could develop in the future to ensure that are „fit for purpose‟ and

provide the best outcomes for patients. The development of these options was supplemented by the views

of other colleagues, staff, patients, interested organisations, and members of the public, as part of an

engagement and involvement programme undertaken during September and October 2011.

These seven options are briefly outlined below:

Option Description

Option 1 Do nothing: This option would leave acute services (including medical and surgical services) at Stoke Mandeville and Wycombe Hospitals, as they are currently organised.

Option 2 Duplicate full acute services on both sites and staff services to required levels for safety: This duplication would require investment, including A&E and emergency and medical services in both Stoke Mandeville and Wycombe Hospitals.

Option 3 Reconfigure acute services in one network: The network would be between the two Buckinghamshire acute hospitals (with links to Wexham Park Hospital in Slough and for vascular services to the Oxford University Hospitals).

Option 4 Centralise acute services on the Stoke Mandeville Hospital site: Only limited services, such as outpatients, would be provided at Wycombe Hospital. There would be an increase in patients using Wexham Park Hospital.

_________________________

6 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire:

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Option Description

Option 5 Centralise acute services on Wycombe Hospital: Only limited services, such as outpatients, would be provided at Stoke Mandeville Hospital. There would be significantly increased activity at Oxford University and Milton Keynes Hospitals because of the geography and access at the north of the county.

Option 6 Provide limited acute services in Buckinghamshire, with all specialised care provided from outside Buckinghamshire: Limited acute services, such as outpatients, would be provided at Stoke Mandeville and Wycombe hospitals. All specialised acute care would be provided from outside Buckinghamshire.

Option 7 Develop a new hospital to serve the Buckinghamshire population.

A high level options appraisal was undertaken at the Buckinghamshire Clinical Commissioning Board and

through local clinical summits, it was concluded that:

Options 1, 2, 4, 5, 6 were rejected at the initial stage of consideration, given that they are unachievable for

the following reasons:

They do not meet the clinical needs of the local population, and are not clinically supported;

They do not offer high quality, safe and sustainable patient services;

They restrict accessibility to some parts of the population;

They do not meet the financial needs of the organisations involved; and

They do not advance the views expressed during public engagement.

Option 3 was therefore been identified as the preferred option on the following basis:

It will improve patient safety and quality;

It will support the retention of staff and clinical expertise;

It best balances geography and population needs;

It will enable complementary roles for the Stoke Mandeville and Wycombe hospitals to be established,

with strong links both with other acute hospital providers and community services;

It builds on the views expressed during public engagement; and

It has been assessed to be affordable now and in the future.

2.3.2 Proposals for reconfiguring services

In developing the preferred option, Option 3, BHiB have been working collaboratively with stakeholders

from Buckingham Healthcare NHS Trust, the Clinical Commissioning Groups and at the Clinical

Commissioning Board which brings together clinical and other staff from the NHS and partner

organisations. Proposals have also been discussed at two „clinical summits‟ which involved a range of

clinicians including hospital doctors and GPs. BHiB have also considered service models and evidence

from across the country.

Under Option 3, the following services will be impacted:

Emergency care;

General medicine inpatient care, including gastroenterology, diabetes and respiratory services;

Elderly inpatient care;

Breast assessment and outpatient services; and

Specialist complex „networked services‟ (vascular services).

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For the majority of patients, the proposed reconfiguration will mean no change. Patients requiring

admission may be impacted by the proposals.

The table below provides further detail on the configuration of these five services across Stoke Mandeville

Hospital (SMH) and Wycombe Hospital (WH). The proposals will also build on the recent investment made

in community hospitals or community services and will:

See specialist consultant roles working in the community taking a more preventative approach to

healthcare;

Develop step-down facilities for older people who no longer require acute care but are not ready to be

cared for at home; and

Will ensure that community services can focus on admission avoidance and will provide 24 hour cover.

Table 2.1: Configuration of these five services under BHiB proposals (based on Option 3)


Emergency Care No change proposed to the Accident and Emergency Department (adult and children, including trauma and GP-led centre)

For those who currently attend the Emergency Medical centre (EMC) at Wycombe without having seen their GP or another clinician first, they will still be able to attend the new minor injury and illness service. GPs and the ambulance service will direct those requiring urgent hospital attention to the most appropriate A&E department (e.g. Stoke Mandeville or Wexham Park hospitals)


Proposal for emergency respiratory, gastroenterology, diabetes inpatient admissions to be centralised and admitted to Stoke Mandeville Hospital

Creation of a step-down ward for those who no longer need acute hospital care at Wycombe Hospital

Elderly Care Proposal for elderly admissions to be admitted to Stoke Mandeville Hospital

Day assessment unit: new service development for Wycombe Hospital. GPs will be able to refer patients into this service and obtain advice and support for patients to remain out of hospital

Breast Services Stoke Mandeville Hospital will not provide these initial assessment and outpatient appointment services as these will be provided at the new Wycombe Centre. Follow up breast care and chemotherapy will remain at Stoke Mandeville

Proposal to centralise initial assessment and outpatient appointments at Wycombe Hospital through the creation of one-stop clinics in a new specialist breast care unit. Follow up breast care and chemotherapy to remain at Wycombe Hospital

Specialist networked services (Vascular)

No change proposed to current service profile Day surgery, diagnostics, outpatients and surgery to prevent strokes caused by carotid artery disease would remain unchanged. Complex inpatient vascular surgery (including abdominal aortic aneurysms) proposed for John Radcliffe Hospital in Oxfordshire

Supporting these developments, there will be a system of fast access for diagnostics, assessment and

specialist opinion for GPs to help keep patients out of hospital.

The service specific impacts associated with each of these five services areas are discussed in Chapters 4

to 8.

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2.3.3 Implementing the proposals

The public consultation debating these proposals closed on the 16 April 2012. Should Option 3 be agreed,

the BHiB programme would be implemented on a phased basis, from August 2012, over a period of 18

months.

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3.1 Background to impact assessments

3.1.1 Health impact assessments

HIAs are a mechanism by which potential effects on health outcomes and health inequalities can be

identified and redressed prior to implementation7. The definition of an HIA is:

“A combination of procedures, methods and tools by which a policy, programme or project may be judged

as to its potential effects on the health of a population, and the distribution of those effects within the

population”.8

The aim is to explore the positive and negative consequences of proposals and produce a set of evidence-

based, practical recommendations, which can then be used by decision-makers to maximise the positive

impacts and minimise any negative impacts of proposed policies or projects.9 Analysis is undertaken for all

of the population but also highlights if and where certain sections of the population will be affected, either

geographical communities or, in particular, certain socio-economic or equalities groups.10

Assessment of impacts and recommendations on opportunities and mitigations are based on the

participation of relevant and informed stakeholders, thereby giving the HIA independence and democratic

legitimacy.11

Objectives of a HIA

Source: DH (2010): „Health Impact Assessment of Government Policy‟

_________________________ 7 D. Acheson (1998) Independent Inquiry into Inequalities in Health, Stationery Office, London, www.archive.official-

documents.co.uk/documents/doh/ih/contents.htm 8 European Centre for Health Policy (1999), Health Impact Assessment: main concepts and suggested approach (Gothenburg

Consensus Paper), Brussels, www.who.dk/document/PAEGothenburgpaper.pdf, p 9 Taylor, L. and Quigley, R. (2002) Op.cit

10 DH (2010): „Health Impact Assessment of Government Policy: A guide to carrying out a Health Impact Assessment of new policy as part of the Impact Assessment process‟

11 NHS Executive London (2006): „A short guide to Health Impact Assessment: Informing health decisions‟

www.londonshealth.gov.uk

3. Impact assessment methodology

http://www.archive.official-documents.co.uk/documents/doh/ih/contents.htm

http://www.archive.official-documents.co.uk/documents/doh/ih/contents.htm

http://www.who.dk/document/PAEGothenburgpaper.pdf

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3.1.2 Equality Impact Assessments

An EqIA is a systematic assessment of the likely or actual effects of policies or proposals on particular

social groups with the following protected characteristics (as defined by the Equality Act 2010):12

Age

Disability

Gender reassignment

Pregnancy and maternity

Race (including ethnic or national origins, colour or nationality)

Religion or belief (including lack of belief)

Sex

Sexual orientation

Marriage and civil partnership

It is important to note that impacts are not universal. Benefits to service users will not necessarily benefit all

protected groups. Equally, protected groups will not all experience the same impacts – some may benefit,

some may not and the types of impacts they will experience could be different in type of magnitude.

Determining which protected groups policy or service changes are relevant to is important in order to

prioritise and plan effectively equality assessment and analysis.13

As such, the primary objectives are to: (a) assess whether one or more of these groups could experience

disproportionate effects (over and above the impacts likely to be experienced by the general population)

as a result of the way in which a service is delivered; (b) identify opportunities to promote equality more

effectively or to a greater extent; and (c) develop ways in which to remove or mitigate any

disproportionate negative impacts to prevent any unlawful discrimination and minimise inequality of

outcomes.

The ascension of the Equality Act 2010, introduced an Equality Duty14

which placed certain responsibilities

on public sector bodies (and others carrying out public functions), specifying that they should be

consciously thinking about three aims15

as part of the decision-making process. These aims are:

The elimination of unlawful discrimination.

Advancement of equality of opportunity between people who share a protected characteristic (see list

above) and those who do not.

The fostering of good relations between people who share a protected characteristic and those who do

not.

Public bodies are required to have „due regard‟ to the Duty which means that equality issues must influence

the decisions that they reach.16

It is important to note that neither HIAs nor EqIAs do not determine the decision about which option

should be selected; rather they act to assist decision makers by giving them better information on how

best they can promote and protect the health and well-being of the local communities they serve.17

18

_________________________ 12

Government Equalities Office (2010): „Equality Act‟ 13

See Equality and Human Rights Commission (2011): „Equality analysis and the equality duty: A guide for public authorities‟ 14

The Public Sector Equality Duty came into force in January 2011 15

Government Equality Office (GEO) (2011): „Equality Act 201: public sector Equality Duty – What do I need to know?‟ 16

GEO (2011): Op. cit.

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3.2 Approach to this assessment

This report presents the findings of the integrated health and equality impact assessment of the five service

areas in which changes have been proposed, as set out in the BHiB consultation document. The following

tasks have been undertaken in order to produce this assessment:

3.2.1 Critique of existing impact assessment evidence

The first phase of this assessment involved a critique of three assessments which had already been

undertaken as shown in the table below.

Table 3.1: Existing assessment documents reviewed

Document 1 Document 2 Document 3

Title Integrated Impact Assessment of BHiB

Equality Impact Assessment of BHiB

Strategic Equality Impact Assessment of the South Central Vascular Surgery Review

Date No date December 2011 July 2011

Author NHS Buckinghamshire and Oxfordshire Cluster

Buckinghamshire and Oxfordshire NHS Cluster and Buckinghamshire Healthcare NHS Trust

NHS South Central Cardiovascular Network

Overview An assessment of the BHiB proposals, covering a wide range of indicators undertaken using Buckinghamshire County Council‟s proforma.

The assessment follows the SHA‟s EqIA approach. It looks at the proposals for emergency care, elderly care, breast services and vascular services.

The assessment follows the SHA EqIA approach. This is a Strategic Health Assessment level assessment which concentrates on vascular surgery proposals only.

This purpose of this exercise was to examine existing information and determine the gaps in impact

assessment evidence. The conclusions reached from this review were that an integrated assessment

was required which:

Considers each service in which changes are being proposed discreetly with a dedicated chapter for

each service. This would allow a better understanding of the health and equality impacts of each

specific service proposal.

Develops recommendations for improvement and mitigation.

Includes an overall chapter which looks at impacts at a programme level.

3.2.2 Compilation of the integrated impact assessment

This has included the following tasks:

Literature review: a substantial literature review has been undertaken reviewing clinical and other

published evidence to identify potential health impacts and outcomes associated with the

reconfiguration of each service; those equality groups within society most likely to experience certain

health conditions and, therefore, are most likely to be affected service changes.

_________________________ 17

Kemm, J. (2007), More than a statement of the crushingly obvious: A critical guide to HIA, West Midlands Public Health Observatory.

18 Taylor, L et. al. (2002): Op. cit.

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Screening of equality groups: based on the research into the propensity of different equality groups to

need certain types of care, for each service area under review equality groups were „screened-in‟ or

„screened-out‟. This ensures that the HIA/EqIA focused on those equality groups which are likely to

experience disproportionate impacts (that is, impacts over and above those experienced by the

general population) from each service change.

Socio-demographic analysis: equality group density data for Buckinghamshire was gathered in order

to understand the locations in which there are high numbers of those populations most vulnerable to

services changes.

The above tasks have enabled the following outputs:

For each service area under review health outcomes; the number of people that could19be affected;

and the potential impacts on equality groups, due to their demographic distribution within the county,

has been analysed and presented.

Impacts relevant to the overall programme (or most service areas) have been identified. Where certain

equality groups are likely to experience disproportionate impacts this has been highlighted.

Recommendations and mitigations have been suggested based on best practice and literature review

evidence. These steps are intended to maximise the quality and equality of health outcomes.

3.3 Assumptions and limitations

It is important to set out the assumptions and limitations that have underpinned this assessment and the

methodological approach. These are set out below:

3.3.1 Assumptions

This assessment has been based on the following assumptions:

The rationale and principles behind the proposals are not challenged. This assessment is not

designed to justify, defend or challenge the rationale or principles behind proposed reforms put forward

in BHiB. It has also been undertaken based on the assumption that any emerging proposals will be

designed with the objective of realising benefits for all people requiring the services under review in

Buckinghamshire, thereby helping improving outcomes for patients.

The purpose of the assessment is to inform rather than decide. As indicated above, the objective of

this HIA/EqIA is not to determine the decision, but to assist decision makers by providing better

information.20

Impacts on socially deprived communities have been considered within this assessment. Social

deprivation is not one of the protected characteristics covered by the Equality Act (see section 3.1.2

above). However it was considered prudent that this assessment considered the impacts on people

living in deprived areas due to the well-documented links between socio-economic disadvantage and

poorer health outcomes. As highlighted in the 2010 Marmot Review21

„there tends to be a social

gradient in health – the lower a person‟s social position, the worse his or her health.‟

_________________________ 19

See assumptions and limitations 20

J Kemm (2007), More than a statement of the crushingly obvious: A critical guide to HIA, West Midlands Public Health Observatory. 21

Marmot, M. (2010) „Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England post 2010‟

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3.3.2 Limitations

The following limitations should be taken into account when considering of the findings of this assessment:

The assessment was undertaken through the review and analysis of available secondary data such as

publicly available reports, policies and some transport modelling data provided by the BHiB team.

There has not been any consultation or primary research undertaken in the production of this

assessment.

In each of the service chapters, an indication of the numbers of people affected is provided. It is

important to note that no independent patient activity modelling has been undertaken. Numbers have

been taken from the scenario modelling provided by BHiB and are based on scenario 3.

For some service areas, specific figures for the numbers of people affected were not available because

they had combined with patient figures that relate to other service areas. Quantification of impacts for

these services in this assessment is, therefore, less precise.

In the absence of activity data which assigns patient flows to wards or Lower Super Output Areas,

impacts on equality groups are explained in terms of general density and distribution. There is no

quantification of the numbers of patients from each group that could be affected. Commenting that an

equality group could be disproportionately affected does not mean that all or most people from within

this group will be affected.

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This chapter presents the health and equality impact assessment findings of the proposed emergency care

services reconfiguration.

4.1 Services changes under review

The services being considered within this element of the reconfiguration proposals are those that are

provided for patients who require emergency care services, including those needing emergency and urgent

care for those requiring less intensive interventions for minor injuries and illness.

4.1.1 Current configuration

Currently, there are two emergency departments in Buckinghamshire. Stoke Mandeville Hospital provides a

full A&E, linked with the trauma unit and emergency surgery, and Wycombe Hospital provides an

Emergency Medical Centre (EMC). Both departments see patients who are transported by ambulance or

through GP referrals in addition to those people who walk in with minor injuries and illnesses. Both offer a

GP service as well. Stroke and cardiac patients are seen in Wycombe Hospital only.

Neither of the two emergency departments have the levels of consultant staffing recommended by the

College of Emergency Medicine22

to provide 24/7 consultant cover; considered to provide safe patient care,

and neither department currently sees a sufficient volume of attendances to be able to maintain the skills if

additional consultants were recruited to meet these recommended staffing levels.

4.1.2 Reconfiguration proposals

A detailed assessment of options for consultant led emergency care services has been considered by

BHiB, which have included keeping services at both Stoke Mandeville and Wycombe Hospitals or

centralising services at one site. Following this, under BHiB, the proposal is to develop consultant led A&E

services at Stoke Mandeville Hospital in order to centralise service provision in Buckinghamshire for the

most seriously ill and injured patients; ensuring a high quality and sustainable service.

A minor injury and illness service will be based at Wycombe Hospital; accessing all hospital diagnostic and

consultant advice. This service would be supported by emergency nurse practitioners and GPs who would

be able to see, treat and discharge many of those patients who currently attend the Emergency Medical

Centre but do not require admission. This service will be integrated with the emergency services at Stoke

Mandeville to ensure appropriate governance, common protocols and continuing professional

development. This service would be moved into a modern part of the hospital.

Emergency services for stroke and cardiac patients will remain at Wycombe Hospital, but with direct

access rather than through the EMC.

In addition, there are current ongoing discussions about the opening hours of this minor injury and illness

service. Eighty-four per cent of attendances which would be appropriate for this service, present during the

hours of 8am-10pm.23

_________________________

22 College of Emergency Medicine – Workforce Recommendations, 2010 23

Immediate Public Access to Care and Treatment, Demand for Urgent Care Services at Wycombe, April 2012

4. Emergency care and urgent care

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4.2 Health Impacts

4.2.1 Health outcomes

Centralising consultant led A&E services on the Stoke Mandeville Hospital site will enable the Trust to

ensure that it can provide the high quality and safe service for the people of Buckinghamshire; making best

use of the emergency care consultant staff to provide 24/7 cover. Under the configuration of services

outlined by the BHiB programme, acute medical inpatient care will be centralised on the Stoke Mandeville

Hospital site where there is already a trauma unit and emergency surgical and intensive care services; with

the exception of cardiology and stroke inpatient services which will continue to be provided at Wycombe

Hospital. This will mean that this site is able to care for the range of complex and unselected

emergency presentations and achieve better outcomes.

The move towards centralisation of hospital services is endorsed and recommended by many of the Royal

Colleges. The Academy of Medical Royal Colleges states that for a District Hospital with paediatrics and

some specialist surgery it needs all key supporting services including full emergency medicine (A&E)

service, acute medical and surgical beds, medicine for the elderly, adult intensive care unit and 24 hours

imaging and laboratory services.24

In addition, the Royal College of Physicians recommends the

development of major acute hospitals serving local regions, providing the most intensive level of

emergency and complex acute medical care. It considers that these hospitals should have major

emergency departments co-located with the acute medical unit and critical care units.25

Therefore, for the

complement of services proposed to be provided on the Stoke Mandeville Hospital there is a requirement

for this site to have an A&E service to ensure it achieves better outcomes and care for patients.

This proposed reconfiguration is also supported by research published by the Kings Fund which suggests

that through consolidating A&E departments, supported by developing specialist centres for medical

services, hospitals with A&E departments can deploy more specialist and experienced staff and deliver

better 24-hour coverage. This can lead to better results, including reduced mortality from serious illnesses

and injuries.26

This is supported by further research undertaken by The College of Emergency Medicine

which advocates the consultant-led care model that a consolidated A&E department would enable,

highlighting the benefits to patients of reduced waiting times, more appropriate hospital admissions,

decreased length of stay and fewer onward specialist referrals.27

The Academy of Medical Royal Colleges further states that whilst a local hospital without surgery/paediatric

and orthopaedic 24 hour services may be able to care for 80-90% of the emergency department and

medical workload, there would be a significant number of transfers to other hospitals and the need for

effective use of bypass protocols with the ambulance service. It states that the logistical challenges in

arranging transfers and the resultant impact on patient care and on the medical workforce should not

underestimated together with the clinical and financial viability of the service.

_________________________

24 Acute health care services, Academy of Medical Royal Colleges, 2007

25 Acute medical care: The right person, in the right setting – first time, Royal College of Physicians, 2007

26 The Kings Fund (2011) Reconfiguring Hospital Services; Lessons from South East London

27 Emergency Medicine Consultants, Workforce Recommendation, The College of Emergency Medicine, April 2010

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The above evidence is further supplemented by the Kings Fund who report that whilst delay for people with

life-threatening conditions is linked to poorer outcomes, it is the timing of the start of appropriate treatment,

rather than the timing of arrival at hospital that affects the outcome. Therefore, interventions by

paramedics and/or rapid access to the specialist team once at the hospital can offset or overcome

the risk created by the additional travel time.28

29

The model proposed for Wycombe Hospital provides access a GP led minor injury and illness service, with

GP out of hours services based at the Hospital. This GP led minor injury and illness service is a model

recognised by the Academy of Medical Royal Colleges, which sees this type of service providing some

imaging/tests, simple treatments such as suturing/plaster of Paris. There are many examples across the

country of successful developments in the provision of urgent care centres and minor injury units.

Finally, it is important to recognise that the provision of emergency and urgent care services across the two

sites will form part of a local emergency care network, ensuring integration of services, appropriate clinical

governance, common protocols and continuing professional development.30

Some patients will also be

treated at Wexham Park Hospital, depending on their place of residence, and a few will be seen at other

neighbouring hospitals such as Watford.

4.2.2 Who and how many will be impacted by the proposals?

The impact of this proposed reconfiguration of emergency care service will impact those living in and

around Wycombe who would have accessed the existing Emergency Medical Centre. The consultation

document estimates that the number of people attending Wycombe Hospital will reduce from 933 a week to

60431

32

with the majority of the other 329 patients a week (with the exception of those with stroke or acute

coronary syndrome33

) accessing services at Stoke Mandeville and Wexham Park Hospitals 34

.

Therefore, approximately one third of those patients who currently access the service at Wycombe

would be affected. This is likely to impact most on those patients who were previously transported by

ambulance to the hospital, either as a result of 999 calls or through GP referrals.

_________________________

28 Spurgeon P, Cooke M, Fulop N, Walters R, West P, 6 P, Barwell F, Mazelan P (2010). Evaluating Models of Service Delivery: Reconfiguration principle. National Institute for Health Research Service Delivery and Organisation programme. London: HMSO.

29 Kings Fund (2011) Reconfiguring hospital services

30 Better Healthcare in Bucks: Response to NCAT report, November 2011

31 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg32.

32 Most recent activity modelling of Scenario 3 estimates that urgent care attendances at Wycombe Hospital would reduce to 666 per week

33 Consultation Document estimates that additional A&E attendances at Stoke Mandeville will average 258 per week. Most recent activity modelling of Scenario 3 estimates that there will be 122 additional attendances at Stoke Mandeville per week.

34 It is estimated that additional A&E attendances at Stoke Mandeville will average 258 (as per the Consultation Document),

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4.3 Equality impacts

This section provides evidence to highlight which equality groups are could have a high need for

emergency care services and, therefore, are most likely to experience disproportionate impacts. For each

of these „screened-in‟ groups potential positive and negative effects of the proposals are then discussed.

4.3.1 Young males

There is much evidence to suggest that young males have a higher propensity to require emergency

services. For example, males are more likely to be involved in road traffic accidents than females,

particularly males under the age of 30 who represent the most common group in speed-related collisions. 35

Young men are at greater risk of being involved in accidents than females. In particular, men are twice as

likely to be involved in (and die from) accidents at work and four times more likely to suffer major accident

while practicing sports.36

However, the majority of accidents of this kind would not be treated at an

emergency or urgent care centre, they would instead be treated as a major trauma case and be taken to

Stoke Mandeville; this is same as at present as no changes are proposed for major trauma services.

As such, even though young men are at a higher risk of accidents, the severity of their conditions means

the centre most likely to treat them will not change. Disproportionate negative impacts are, therefore, not

expected for this group.

4.3.2 Older people (aged 60 and over)

Older people are frequent users of A&E departments; UK research suggests A&E attendances are highest

amongst those between 65 and 80 years of age. Hospital Episode Statistics suggest that 43% of

attendances at A&E in 2010-11 were by people aged over 60, while 28% were by people aged over 75.37

_________________________

35 The characteristics of speed-related collisions: Road safety research report No. 117 (2010) Department for Transport

36 See: East Midlands Public Health Observatory, (2007); „Profile of avoidable injury in the East Midlands: All ages, all causes‟; ONS (1999): „1999 Health Survey for England‟

37 National Statistics / HES Online (2012): „Main specialty‟. See: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=207 'Copyright © 2012 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'

http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=207

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Research by the British Geriatrics Society suggests that older people experience a greater level of

morbidity and are relatively frequent users of A&E departments. One of the most common reasons for

presenting include trauma, which mainly comprise falls (more than 600,000 fall related incidents are

recorded at A&E departments in the UK each year for persons over the age of 6038

). Abuse, delirium and

illness are other key reasons for older people‟s attendance at A&E is due to illness.39

For older patients with major or serious trauma (as with young males above) there will be no impact

proposed by the reconfiguration as these patients already bypass Wycombe Hospital and are taken directly

to the nearest trauma unit or major trauma centre. The day assessment centre at Wycombe is also

expected to prevent the need for emergency admissions whilst any stoke and cardiac patients (a common

condition for older people) will continue to be provided at Wycombe so any older patients requiring this type

of treatment will not be affected by the proposals. However, older people are still high users of general A&E

services; therefore, proportionally, they are likely to be affected by the proposals.

Both of Buckinghamshire‟s main acute hospitals are in close proximity to large numbers of older people.

Given that there are high densities of older people within the southern towns of the county, the proposed

focus on emergency care in Stoke Mandeville Hospital is likely to lead to disproportionate impacts for older

people in terms of change to their usual service and longer travel times to access A&E services.

See Figure A.2 in Appendix A for the density and distribution of older people in Buckinghamshire.

4.3.3 BAME groups

There is some evidence to suggest that people from BAME present more frequently at A&E than other

sections of the general public as set out below:

People from groups born outside the UK tend to settle in urban, inner city areas where poverty,

deprivation, health and social risks are already present. BAME and deprived groups are also more likely

to undertake more physical labour or low status manual work, placing them at greater risk of physical

injury, occupational health problems and other health issues.40

In addition, BAME communities who need to access NHS services sometimes do not know how to,

particularly refugees and asylum seekers, and are particularly vulnerable to poor health. BAME groups‟

access to healthcare is often restricted by language, communication and cultural barriers, especially for

older generations who tend to speak less English than the younger members of their families.

Presenting at an A&E department, therefore, may seem the easiest ways for these communities to

access healthcare – even if not an emergency.

_________________________ 38 Scuffham P, Chaplin S, Legood R. (2003): „Incidence and cost of unintentional falls in older people in the United Kingdom‟. J Epidemiol Community Health 57: pp.740-4. See: http://www.bgs.org.uk/index.php?option=com_content&view=article&id=45:gpgaae&catid=12:goodpractice&Itemid=106; 39 Downing A, Wilson R. Older people's use of Accident and Emergency services. Age Ageing. 2005; 34: 24-30

40 Michael Joseph (1994) : „Sociology for Nursing and Health Care‟; Michael Senior, Bruce Viveash (1998) : „Health and illness‟, p.165

http://www.bgs.org.uk/index.php?option=com_content&view=article&id=45:gpgaae&catid=12:goodpractice&Itemid=106

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The Home Office collects only limited data on the ethnicity of the victims of violent crime; although

figures on the ethnicity of homicide victims killed by „sharp instruments‟, for the decade to 2006 indicate

that that each year, on average, 12 per cent of homicide victims by sharp instrument have been black –

around five times over-represented against population estimates. People from Asian ethnic background

occupy a similar position, accounting for each year, on average, seven per cent of victims.41

As with the social groups identified above, in cases of trauma patients (knife crime and serious accidents)

already and will continue to get taken to the trauma unit at Stoke Mandeville and some less severe injuries

will be able to receive treatment at the minor injuries and illness centre at Wycombe. Another important

point to make, as with older people above, is that the most common reason for emergency admission is for

strokes and other cardiac problems; certain BAME communities have a higher pre-disposition to

experiencing these conditions. 42

Stroke and cardiac services will continue to be provided at Wycombe so

any BAME patients requiring this type of treatment will not be affected by the proposals.

The above mitigations aside, it is still important to note that there could be some minor disproportionate

impacts on BAME communities given their higher susceptibility and general (average) poorer health.43

The highest numbers and densities of BAME groups in the south of the country, particularly around High

Wycombe. Amersham, Beaconsfield, and Chesham. Given this high concentration there is the potential for

disproportionate impacts for BAME groups as a result of the emergency care proposals because A&E

services will be much further away in future.

Figure A.5 in Appendix A shows the distribution and density of BAME groups in Buckinghamshire.

4.3.4 Deprived communities

Socio-economic factors are known to be powerful determinants of health. Life expectancy tends to be

shorter in areas of deprivation and relative poverty and poorer people tend to make higher use of primary

care and emergency departments, whilst making lower use of services, such as screening and

immunisations. This lack of preventative care can be a key cause of deprived groups‟ over-representation

in the use of acute care and through A&E.44

Whilst the increased investment in community care is likely to prevent hospital admissions, given generally

poorer health levels, those from socio-economically deprived communities are still more likely to require

emergency services than those from more affluent areas.

_________________________

41 „Knife Crime‟ A review of evidence and policy (2007) Centre for Crime and Justice Studies 42

There is a lot of evidence to suggest that rates of stroke and cardiac conditions are higher in certain BAME communities, particularly South Asian communities.

43 This statement does not suggest that all people from BAME communities have poorer health; rather it suggests that the rate of poorer health tends to be higher amongst BAME groups.

44 ONS (2011): „Health Survey for England‟; NHS East Midlands (2007): „Health Impact Assessment and Equality Impact Assessment for major trauma services‟

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There are relatively low levels of deprivation within Buckinghamshire; the highest concentrations of

deprivation are around Aylesbury which is itself in close proximity to Stoke Mandeville Hospital. As such,

whilst those from socio-economically deprived areas may be at higher risk of requiring emergency services,

the extent of the impact (i.e. numbers of people potentially negatively affected) will be low; instead they are

likely experience net benefits as emergency care services will be strengthened in this area. It is worth

noting that there are some small pockets of deprivation around High Wycombe which will be further away

from an A&E department in future; however numbers of people in these areas are small. In summary, BHiB

may need to put some thought into addressing possible mitigation measures for this group but the areas in

which these need to be targeted will be few.

Figure A.6 in Appendix A illustrates the Indices of Multiple Deprivation (IMD) ranking of Lower Super

Output Areas (LSOAs) within the county.

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This chapter presents the health and equalities impact assessment findings of the proposed general

medicine inpatient care services reconfiguration.



provided for patients who require acute medical care from the general and specialist medicine inpatient

services, including gastroenterology, respiratory and diabetes and medicine for older people (see also

Chapter 6 for further details).


Both hospitals currently provide general medical inpatient services. These services suffer the same issue

as emergency care in that there is insufficient consultant staff on each site to provide a high quality and

sustainable service which meets recommended consultant staffing levels and the subspecialisation now

being required to better manage these patients and to satisfy the training requirements of doctors.


A detailed assessment of options for general medicine inpatient services has been considered by BHiB,

which have included keeping services at both Stoke Mandeville and Wycombe Hospitals or centralising

services at one site. BHiB is now proposing that medical admissions are centralised at Stoke Mandeville

Hospital, creating a specialist medical centre for gastroenterology, diabetes care, medicine for older people

and respiratory. This reconfiguration of services is seen as enabling better integration with the other

services to be provided on the Stoke Mandeville Hospital site; including appropriate critical care support.

Outpatient service provision will remain unchanged.

5.2 Health Impacts


Centralising services for general medicine inpatient services onto one site and effectively achieving a

sustainable critical mass of inpatient admissions offers an important opportunity to provide sufficient

consultant staffing and on-call cover. This will enable the care of patients with acute medical care needs

to be managed better through continuity of care by dedicated sub-specialised medical teams and

timely access to these specialist teams may improve patient recovery times. Also, by being on the Stoke

Mandeville Hospital site, patients will have access to the full range of emergency, surgical, critical care and

diagnostic services to support their care. This configuration of service delivery is recommended by the

Royal College of Physicians, which states that patients with acute medical illness should get access as

soon as possible to a competent clinical decision maker and that access must be extended out of

hours across the full spectrum of acute care supported by better access to diagnostic services.45

_________________________


5. General medicine inpatient care

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This proposal is in contrast to the current configuration where, given the current number of available

physicians on each site, these sub-specialised consultants need to partake in a general medicine on-call

rota; resulting in the on-call physician accepting the admission of patients for a range of general medical

conditions and then transferring the care of patients onto the appropriate consultant the following day. This

transfer of care is seen to result in delays in treatment and longer lengths of stay.

5.2.2 Who and how many will be impacted by the proposals

The consultation document identifies that these proposals for those requiring urgent care or medical

admission will affect 7,600 people per year. This equates to 3% of people currently using Wycombe

Hospital. In the main, it will be those residents living in Wycombe and the surrounding area who will be

most affected by the proposed changes.

Currently, there is an average of 158 emergency medical admissions to Wycombe Hospital a week.

Following the reconfiguration, it is estimated that of these admissions, 43 will be for stroke and cardiology

patients and so will continue to be provided in Wycombe.46

It is not expected that all of the remaining 115

cases will all transfer to Stoke Mandeville or another acute provider as some admissions are likely to be

prevented with patients supported at home by GPs and other services. Based on the above assumptions,

and as outlined in the consultation document, it has been estimated that Stoke Mandeville Hospital will

admit an additional 3647

acute medical patients (general and elderly care). This includes three

respiratory and one gastroenterology admission per week. A number of emergency medical

admissions are also likely to transfer to Wexham Park rather than Stoke Mandeville given the geographical

convenience for patients.48


This section provides evidence to highlight which equality groups are likely to have a high need for acute

medical services that are subject of the general medicine inpatient care review. For each of these

„screened-in‟ groups potential positive and negative effects of the proposals are then discussed.

5.3.1 Older people

Older people are an equality group which requires critical consideration in terms of the review of acute

medical inpatient services. They are a key patient group for many of the services which are set to be

reconfigured as evidenced below:

_________________________

46 Wycombe Hospital will continue to admit emergency cardiac and stroke patients as at present and will retain the vascular operations which prevent stroke from carotid artery disease (CEA).

47 This is in line with the Consultation Document and the modelled Scenario 3.

48 Within modelled Scenario 3, it is estimated that there will be 28 additional medical admissions at „other‟ hospital providers each week, of which a proportion will be for elderly patients. Scenario 3 breaks down „other provider‟, estimating that 86% of these additional admissions will go Wexford Park and 14% to Watford General.

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Gasteroenterology: Because of the varied nature of gastro-intestinal conditions (there are hundreds of

different ailments ranging from the minor to the life threatening), it is hard to gauge the need for

gastroenterology services amongst specific social groups based on clinical propensity towards certain

conditions. Nonetheless, Hospital Episode Statistics (HES), the main database of hospital admission

episodes in England, indicate that of the 765,333 „consultant episodes‟ for gastroenterology for 2010-11,

54% involved patients over 60, and 24% involved patients over 75.49

Older people, therefore, are

statistically more likely to require gastro-intestinal care than other parts of the general population.

Diabetes: As people age, their risk of developing diabetes increases. Type 2 diabetes amongst older

people is a growing problem and a large proportion of newly diagnosed diabetics are in older age

groups. Diabetes in older people is the product of a complex interaction between the process of ageing,

major metabolic disturbance, vascular disease and functional/mobility loss. Cognitive dysfunction,

depressive illness and falls are also important complications which can lead to the onset and diagnosis

of diabetes. In understanding the population need, studies undertaken on behalf of the NHS in the UK

suggest that as many as one in four older people in residential nursing care will have diabetes.50

However, the impact on inpatient services would be minimal given that the majority of patients with

diabetes can be cared for in an outpatient or community setting.

Respiratory: The average patient age for respiratory services is 63, making older people far more likely

than people of other age groups to require such services. HES statistics indicate that there were

334,359 „consultant episodes‟, 62% of which involved treatment of patients aged over 60, and 32% of

which involved treatment of patients over 75.51

Death from respiratory conditions is also high (16% of

over 65s died from respiratory diseases in 2008).52

The fact that outpatient services will remain the same under the proposed reconfiguration will limit the

impacts on older people. In addition, assuming sufficient and timely bed availability, the „step-down‟

facilities at Wycombe should enable the length of stay at Stoke Mandeville to be relatively short before

being transferred closer to home for treatment. These mitigations will help to minimise the impacts on older

people, but this group is still expected to experience disproportionate effects from these proposals,

especially given the high numbers of older people in the southern towns of the county.

Figure A.2 in Appendix A shows the density and distribution of people over 60 in Buckinghamshire.

5.3.2 People from BAME groups

Ethnicity is a particularly pertinent risk factor in requiring diabetes care. International and UK studies have

shown that people from South Asian ethnic backgrounds in particular are up to six times more likely to

develop Type 2 diabetes than people from white backgrounds.53

In addition, people from African and

African-Caribbean backgrounds are at least three times more likely to be diagnosed with Type 2 diabetes.

Diabetes support groups in the UK consider that a person‟s risk of developing diabetes increases

_________________________

49 National Statistics / HES Online (2012): „Main speciailty‟. See: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=207 'Copyright © 2012 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'

50 Source: NHS Diabetes. See: http://www.diabetes.nhs.uk/networks/older_people_network/

51 National Statistics / HES Online (2012): „Main specialty‟. See: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=207 'Copyright © 2012 Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.'

52 DH – Committee on Medical Effects of Air Pollutants (2006)

53 See: http://www.diabetes.co.uk/diabetes-and-ethnicity.html Reference from „Balance‟ (January – February 2010), the UK‟s main diabetes publication.


http://www.diabetes.nhs.uk/networks/older_people_network/


http://www.diabetes.co.uk/diabetes-and-ethnicity.html

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significantly over the age of 40 for people from white backgrounds. That age falls to 25 for people of Black

and Asian backgrounds.54

Buckinghamshire‟s own Joint Strategic Needs Assessment (JSNA) identifies that Type 2 diabetes is more

common in people of Asian, African, Afro-Caribbean, Middle Eastern and Chinese descent. It also identifies

that the more deprived areas of Buckinghamshire have a higher proportion of ethnic groups at increased

risk of diabetes, such as Pakistani Asian populations. 55

Whilst BAME groups are particularly susceptible to diabetes in terms of numbers, those affected will be

limited due to the retention of outpatient services at Wycombe It is expected that the majority of patients‟

treatment will go unchanged. So even though BAME groups are more likely to experience the impacts of

these proposals any disproportionate effects will be very small given the very small number of overall

inpatient admissions for diabetes.

In terms of demographic distribution of BAME communities throughout Buckinghamshire, densities are

highest in the south of the county, particularly around High Wycombe, Amersham, Beaconsfield and

Chesham. Concentrating acute diabetes inpatient facilities at Stoke Mandeville has the potential, therefore,

to have disproportionate adverse effects for BAME groups who require inpatient services.

See Figure A.5 in Appendix A for the density and distribution of people from BAME communities.

5.3.3 Disabled people

It is important to note that disabled people are not a homogenous group; the needs of those with mobility

disabilities can be very different to those with visual impairments. In the case of acute medical inpatient

services disabled people with learning disabilities and mental health illnesses are considered to be a high

risk group, as the evidence below indicates.

Diabetes: People with learning disabilities are more prone to developing diabetes than those without

learning disabilities. This may be attributed to increased levels of obesity, poor diet and inactive

lifestyles.56

Respiratory: Respiratory disease is the main cause of death in people with learning disabilities. They

are at risk of respiratory tract infections caused by aspiration or reflux if they have swallowing

difficulties.57

Death rates from respiratory diseases are far higher for those with learning disabilities

(around 50%) than for those without (around 15%).58

People with Down‟s Syndrome are particularly at

risk because they have a predisposition to lung abnormalities, a poor immune system and a tendency to

breathe through their mouth.59

Whilst numbers of people falling into this category may be small, given the high propensity for those with

learning difficulties to need the above services, they are a group which could well experience

_________________________

54 Diabetes UK (2012): „What are the risk factors?‟. See http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/What_are_the_risk_factors/

55 NHS Buckinghamshire and Buckinghamshire County Council (updated 2011) „Joint Strategic Needs Assessment‟ 56

Royal College of Nursing (2011): „Meeting the needs of people with learning disabilities‟ 57

Royal College of Nursing (2011): Op. cit. 58

Hollins S, Attard M, van Fraunhofer N, McGuigan SM, Sedgwick P (1998):.‟Mortality in people with learning disability: risks causes, and death certification findings in London.‟ Developmental Medicine and Child Neurology 40:50-56. Cited in: Emerson, E. and Baines, S. (2010): „Health inequalities and people with learning disabilities in the UK‟

59 Royal College of Nursing (2011): Op. cit.

http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/What_are_the_risk_factors/

http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/What_are_the_risk_factors/

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disproportionate impacts from the BHiB review. In developing and implementing mitigation measures, this

group and, where relevant, their carers will need to be considered.


Those living in deprived areas have a higher incidence of long term medical conditions. Buckinghamshire‟s

JSNA recognises that the higher frequency of risk factors such as smoking, obesity, and alcohol

consumption in more deprived populations contributes to the poorer health and increased risk of long term

conditions. 60

Socio-economic factors are known to be powerful determinants of health; life expectancy tends to be

shorter in areas of deprivation and relative poverty. Poorer people tend to make lower use of screening and

immunisations as well as other preventative services, which will put them at greater risk of requiring

inpatient services to remedy poor health conditions.61 The possibility of requiring emergency medical care

services is also therefore likely to be greater for those from deprived backgrounds.

There are relatively low levels of deprivation within Buckinghamshire; none of the county‟s Lower Super

Output Areas (LSOAs) are within the „most deprived‟ IMD quintile (the most deprived 20% of areas in the

country). The highest concentrations of deprivation are around Aylesbury which is itself in close proximity to

Stoke Mandeville Hospital. As such, similar to the emergency care proposals above, it is not anticipated

that there will be any disproportionate negative effects for people from low income backgrounds. Instead, it

is possible that people from deprived communities could experience net benefits as general medicine

inpatient care will be strengthened where deprivation levels are highest. As with emergency care above in

chapter 4, it is worth noting that there are some small pockets of deprivation around High Wycombe which

will, under the BHiB proposals be further away from general medicine inpatient services; however numbers

of people in these areas are small.

See Figure A.6 in Appendix A for the distribution of deprived communities across the county.

_________________________

60 NHS Buckinghamshire and Buckinghamshire County Council (updated 2011): Op. cit.

61 Robin Carlisle, Lindsay M Groom, Anthony J Avery, Daphne Boot, Stephen Earwicker (1998) : „Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey‟, British Medical Journal 316, pp.520-523; Sally Hull, Ian Rees Jones, and Kath Moser (1998) : „Relation of Rates of self-referral to A E departments to deprivation‟, British Medical Journal 317, p.538

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This chapter presents the health and equalities impact assessment findings of the proposed elderly care




provided for patients who require elderly care services. This includes those elderly patients with acute

medical needs, rehabilitation and those who can be supported at home.62


As with general medicine inpatient services, the current configuration of elderly care inpatient service

provision is split across the two sites, which impacts on the ability to provide continuity in care due to the

limited number of available consultants at each site.

Nationally and within Buckinghamshire, over the past years, much work has been done to develop high

quality, community-based services so patients can be cared for in their own homes or much closer to

home. As a consequence of these developments, when people are admitted to hospital it is for a shorter

length of time. However, the health community recognises that more needs to be done through the

continued development of community-based services to further reduce unnecessary admissions to

hospital.


A detailed assessment of options for centralising elderly services and also reducing the need for admission

has been considered by BHiB. Options considered have included keeping services at both Stoke

Mandeville and Wycombe Hospitals or centralising elderly care provision on one site. Based on this review,

the BHiB proposal is that older people who require hospital care when they are acutely unwell, should be

treated at a specialist inpatient centre at Stoke Mandeville Hospital.

To support both the acute inpatient service and the community-based services, an elderly care service is to

be developed at Wycombe Hospital; providing an intermediate level of care comprising:

A multidisciplinary assessment service providing same day or next assessments; seeking to provide

support and care in the patient‟s own home.

A „step down‟ ward to care for elderly and medical patients who are no longer acutely unwell but whose

condition and requirements cannot yet be met in their own homes.

Access to outpatient services will remain unchanged.

There will be continued investment to develop multidisciplinary community teams so that even more people

can be clinically managed and supported in their own home, thereby avoiding hospital admission.

_________________________

62 It should be noted that for those elderly patients who are acutely unwell, they will be treated within the specialist general medicine inpatient service at Stoke Mandeville Hospital; which is discussed in the service specific Chapter on general medicine inpatient care.

6. Elderly care

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6.2 Health Impacts


The Academy of Medical Royal Colleges states that older people need more targeted services in both the

community and in hospital. It sees that medicine for the elderly should include care at home, supporting

general practice through new models of care. It suggests that hospital services should be more focussed

on specific needs. The Academy considers that many conditions could be managed by a community based

multidisciplinary team treating patients in their own homes.63

This proposed service configuration will build on local work already underway to support the

delivery of increased care in community settings. The shift of care out of a hospital setting and

providing more appropriate care at home or close to home, means that the requirement for inpatient

services will reduce. This is despite the forecast increase in population for those aged 65 years and over.

The NHS Confederation believes that at least 25% of patients in hospital beds could be looked after by

NHS staff at home.64

Due to the proposed bolstering of community care it is likely that demand for acute inpatient services from

older people will reduce. Centralising services for elderly medicine care services onto one site will,

therefore, help to achieve a sustainable service and provide sufficient consultant staffing and on-

call cover. Many elderly patients may have complex co-morbidities and, as with general medicine, by

being on the Stoke Mandeville Hospital site, patients will have access to the full range of

emergency, surgical, critical care and diagnostic services to support their care. This configuration of

service delivery is recommended by the Royal College of Physicians, which states that patients with acute

medical illness should get access as soon as possible to a competent clinical decision maker and that

access must be extended out of hours across the full spectrum of acute care supported by better access to

diagnostic services.65


The consultation document identifies that the proposals for those requiring urgent care or medical

admission will affect 7,600 people per year, of which a proportion will be elderly.66

In total, this

equates to 3% of people currently using Wycombe Hospital. In the main, it will be those elderly residents

living in Wycombe and the surrounding area who will be most affected by the proposed changes.

_________________________

63 Acute health care services, Academy of Medical Royal Colleges, 2007

64 Clinical responses to the downturn, NHS Confederation, 2010


66 It should be noted that the consultation document does not break down this number into „general medicine‟ and „elderly care‟ services; the patients affected have been grouped together. As such it is not possible to quantify in any more detail the number of patients that will be affected by changes to acute elderly services alone.

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Currently there is an average of 158 emergency medical admissions to Wycombe Hospital a week, of

which a proportion will be elderly. Following the reconfiguration, it is estimated that of these admissions, 43

will be for stroke and cardiology patients and so will continue to be provided in Wycombe.67

It is not

expected that all of the remaining 115 cases will all transfer to Stoke Mandeville or another acute provider

as some admissions are likely to be prevented with patients supported at home by GPs and other services.

It has been estimated that Stoke Mandeville Hospital will admit an additional 3668

acute medical

patients (of which a proportion will be elderly)69

although there will also be greater use of community

services. A number of emergency medical admissions are also likely to transfer to Wexham Park rather

than Stoke Mandeville given geographical convenience for patients.70

It is estimated that the elderly „step down‟ ward at Wycombe Hospital will treat on average 10 patients a

week, as part of their rehabilitation from a stroke; 520 patients annually. It is also estimated that 32 patients

a week will attend the day assessment unit at Wycombe Hospital. 71


This section provides evidence to highlight which equality groups are likely to have a high need for elderly

care. For this service, it is considered that older people, given that they are the only recipients of the

service are the only „screened-in‟ group.

Evidence suggests that those people aged 85 or over are 14 times more likely to be admitted to hospital

than someone aged between 15 and 39 years of age; and this population cohort is growing72

. As such, in

terms of scale of impacts, the impacts on this group are essential to consider.

As Figure A.2 in Appendix A illustrates, densities of older people are much higher in the southern part of

Buckinghamshire. This could lead to disproportionate negative impacts for those older people who do

require acute care. However, the number of elderly patients requiring acute care is likely to be small

compared to those who can be treated through community based services where care is administered at

home. This care closer to home is likely to appeal to older people who can find independent travel to health

services problematic. In addition, stays at Stoke Mandeville for those older people who live in the south of

the county are also likely to be fairly brief given the investment in step-down facilities in Wycombe. As such,

whilst those few who will need to travel further for acute services will be disadvantaged, many older people

in the south could see benefits from the new reconfiguration.

_________________________

67 Wycombe Hospital will continue to admit emergency cardiac and stroke patients as at present and will retain the vascular operations which prevent stroke from carotid artery disease (CEA).

68 This is in line with the Consultation Document and the modelled Scenario 3.

69 It should be noted that this number is for both general and elderly care services; the patients affected have been grouped together in BHiB modelling. Not all of these 36 patients will be elderly requiring acute care services.

70 Within modelled Scenario 3, it is estimated that there will be 28 additional medical admissions at „other‟ hospital providers each week, of which a proportion will be for elderly patients. Scenario 3 breaks down „other provider‟, estimating that 86% of these additional admissions will go Wexford Park and 14% to Watford General.

71 As estimated in modelled scenario 3.

72 Buckinghamshire Healthcare NHST (2011) Integrated Business Plan (referencing JSNA)

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This chapter presents the health and equalities impact assessment findings of the proposed breast




provided for patients who require breast services. This includes services to investigate and assess those

patients who are referred to the service by their GP for first assessment.


Currently, breast screening is undertaken at Stoke Mandeville and Wycombe Hospitals and within two

mobile units which visit 15 sites around the county.

It has been recognised that assessment services provided at both Stoke Mandeville and Wycombe

Hospitals are fragmented with clinics being held at various locations in different parts of both hospitals. This

has resulted in privacy and dignity issues and confusion for patients at an often anxious time.

National developments to improve patient experience have also had an impact of the capacity of the

current service. From December 2009, all women with suspected breast problems and not just those with

suspected cancer, are required to be seen by a hospital specialist within two weeks; greatly increasing the

demand for this service.

Those patients who require breast surgery are currently treated at Wycombe Hospital.


A detailed assessment of options for centralising breast services has been considered by BHiB, which as

with other services, include keeping specialist services at both Stoke Mandeville and Wycombe Hospitals

or centralising services at one site. BHiB is now proposing that a new „Centre of Excellence for Breast

Services‟ is developed at Wycombe Hospital with the aim of making it the first choice for both patients and

GPs. This Centre will incorporate state of the art equipment and will provide digital imaging, breast

screening follow-up assessments, and other services for patients, including specialist counselling. It also

needs to have access to specialist imaging (e.g. MRI and nuclear medicine).

It is recognised that the vast majority of breast screening is undertaken within mobile units and access to

these mobile units will be enhanced under the reconfiguration proposals as there will be an additional new

mobile unit established, with disabled access.

Breast surgery services will continue to be provided at Wycombe Hospital.

As a result of these proposals, Stoke Mandeville Hospital will not provide initial assessment and outpatient

appointment services as these will be provided at the new Wycombe „Centre of Excellence‟.

7. Breast services

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7.2 Health impacts


Centralising initial assessment services for patients with breast problems and symptoms of breast cancer

offers an important opportunity to develop a ‘Centre of Excellence for Breast services’; ensuring that

services meet the complex needs of patients and offer the best clinical outcomes and patient

experience. This will mean that staff are co-located on the same site, developing an experienced and

specialised multi-disciplinary breast team who will benefit from the sharing of expertise and

learning across the team.

There is evidence which reflects the importance and role of regional specialist cancer centres that treat

high numbers of patients and so have amassed a greater experience in breast cancer than other hospitals.

Such evidence suggests that such centres of excellence can yield better outcomes for women.73

Centralisation will also standardise and improve the pathways of care for a breast services patient as

they will be able to access services at one location; promoting consistent best practice and providing

every patient with the best outcomes. This is in contrast to the current configuration where it is reported

that services across the two acute hospitals are fragmented and held in various locations in different parts

of both hospitals. One-stop clinics will be offered at Wycombe Hospital and will mean that patients, at

their first appointment, can be seen by a consultant surgeon, consultant radiologist and have all

their tests done at the same time; improving the experience of the patient at a time which can be

distressing. This approach is in line with the NICE Improving Outcomes in Cancer Guidance.74

It is proposed that the Centre for Excellence will be supported by „state of the art technology‟ and it is

reported that investment has already been made in the latest digital mammography assessment equipment

at Wycombe Hospital. Indeed, the hospital is already established as one of the few sites in the country

offering pioneering senital node biopsy surgery. Access to such equipment will ensure that patients receive

timely and appropriate care and the consolidation of services on one site will reduce the inconvenience of

the patient travelling between sites for different tests and appointments. Consolidation may also promote

the efficient use of equipment and facilities.

Finally, the development of a Centre of Excellence in one dedicated location may also strengthen the

opportunity for patients to provide informal and mutual support for each other.


As identified in the JSNA for Buckinghamshire75

, cancer is the second most common cause of death and

most common cause of premature death in Buckinghamshire. In particular, breast cancer is the most

common cancer diagnosed in Buckinghamshire, with alcohol and being overweight acknowledged to

increase the risk of breast cancer. This identifies that in 2006, 435 (19% of all cancer patients) were

diagnosed with breast cancer and it was responsible for 9% of all cancer deaths76

.

_________________________

73 Breast Cancer Care (October 2010) „Equity and Excellence: Liberating the NHS‟

74 NICE (2002) Guidance on Cancer Services: Improving Outcomes in Breast Cancer

75 NHS Buckinghamshire and Buckinghamshire County Council (updated 2011) Joint Strategic Needs Assessment

76 NHS Buckinghamshire and Buckinghamshire County Council (2010) Joint Strategic Needs Assessment, pg 122.

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The BHiB consultation document identifies that these proposals will impact, annually:

200 women whose initial assessments are currently undertaken at Stoke Mandeville Hospital

1,500 women whose outpatient appointments are currently provided at Stoke Mandeville

Hospital

It is recognised that depending on their place of residence, some women may have a preference to be

referred to neighbouring services, such as Milton Keynes or Luton. This patient choice will be supported by

the BHiB.

7.3 Equality groups’ need for breast services

7.3.1 Older women

Naturally, breast services are primarily directed at women; of the approximate 48,000 instances of breast

cancer each year in the UK only 300 are experienced by men.77

Breast cancer is the most common form of

cancer amongst women in the UK and current studies suggest that one in eight women will develop breast

cancer at some point in their life.78

As is the national picture, women are overwhelmingly predominant

users of breast services.

The highest demand for breast services comes from older women. The most significant factor leading to

women requiring breast services is risk of breast cancer and, as with most cancers, this risk increases with

age, becoming most significant between the ages of 50 and 70. Cancer Research UK suggests that 81% of

breast cancer diagnoses are amongst women aged over 50.79

In the UK, since 1988, the NHS has run a Breast Screening Programme in England. At present, all women

between the ages of 50 and 70 are invited for screening every three years. By 2006, breast cancer

registrations at ages 50–64 years had increased by almost 50% since the Breast Screening Programme

began in 1988. About half of this increase is due to screening and about half is due to an increase in the

underlying incidence of breast cancer.80

_________________________

77 Cancer Research UK (2012): „Definite Breast Cancer Risks‟. See: http://cancerhelp.cancerresearchuk.org/type/breast-cancer/about/risks/definite-breast-cancer-risks#page

78 This statistic was established using the AMP method. See: Sasieni PD, Shelton J, Ormiston-Smith N, Thomson CS, Silcocks PB What is the lifetime risk of developing cancer?: the effect of adjusting for multiple primaries. Br J Cancer, 2011. 105(3): p. 460-5.

79 Office for National Statistics (2010): „Cancer Statistics registrations: Registrations of cancer diagnosed in 2008, England. Series MB1 no.39. 2010‟; Information and Statistics Division, NHS Scotland, (2010). See: http://www.isdscotlandarchive.scot.nhs.uk/isd/183.html; Welsh Cancer Intelligence and Surveillance Unit (2010): „Cancer Incidence in Wales‟; Northern Ireland Cancer Registry (2010): „Cancer Incidence and Mortality‟

Source: Cancer Research UK (2012): „Breast Cancer – UK Incidence Statistics‟. See: http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/uk-breast-cancer-incidence-statistics

80 See: http://www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp61.pdf

http://cancerhelp.cancerresearchuk.org/type/breast-cancer/about/risks/definite-breast-cancer-risks#page

http://cancerhelp.cancerresearchuk.org/type/breast-cancer/about/risks/definite-breast-cancer-risks#page

http://www.ncbi.nlm.nih.gov/pubmed/21772332

http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--39--2008/cancer-statistics--registrations-series-mb1.pdf

http://www.isdscotlandarchive.scot.nhs.uk/isd/183.html

http://www.wales.nhs.uk/sites3/page.cfm?orgid=242&pid=21936

http://www.wales.nhs.uk/sites3/page.cfm?orgid=242&pid=21936

http://www.qub.ac.uk/research-centres/nicr/Data/OnlineStatistics/

http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/uk-breast-cancer-incidence-statistics

http://www.cancerscreening.nhs.uk/breastscreen/publications/nhsbsp61.pdf

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As at March 2010, 52,608 women aged between 53-70 years of age, resident in Buckinghamshire were

eligible for the NHS Breast Screening Programme, of which 43,525 were screened.81

In December 2007,

the Department of Health‟s „Cancer Reform Strategy‟ announced that from 2012 the NHS Breast Screening

Programme would be extended to cover women between the ages of 47 and 73.82

Pilots are underway in a

range of areas across the country, with the aim of all women between these ages being screened routinely

by 2015. Demand for breast services, therefore, will continue to rise.

The concentration of women over 45 within the southern parts of the county mean that the majority live

within close proximity to Wycombe Hospital, which has been designated as a future Centre of Excellence

for Breast Services. Women living in the north of the county are likely to see increases in the travel times to

receive breast services, with the disinvestment at Stoke Mandeville Hospital.

See map A.3 in Appendix A for more detailed analysis of the distribution and density of women over 45 in

Buckinghamshire.

_________________________

81 The Health and Social Care Information centre (2011) Breast Screening Programme, England 2009-10

82 See: http://www.cancerscreening.nhs.uk/breastscreen/rollout-age-extension-leaflet.pdf

http://www.cancerscreening.nhs.uk/breastscreen/rollout-age-extension-leaflet.pdf

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This chapter presents the health and equalities impact assessment findings of the proposed complex

vascular surgery services reconfiguration.


The services considered within this element of the impact assessment are those that are provided for

patients who require complex vascular surgery services.83

Given the specialist nature of vascular care and

the availability of specialist consultants to provide high quality twenty-four hour care for patients with

vascular diseases, it is necessary to consider the configuration of these services on a regional basis.

These proposals to reconfigure vascular services are in response to a 2009 report84

, commissioned by the

Vascular Surgery Strategic Group (Network) which concluded that the current arrangements for vascular

service provision are not sustainable. The report made objective assessments and recommendations for

the future development of vascular surgery provision across the South Central region and stated that new

ways of working were required. These needed to include arrangements for larger, combined populations to

create critical mass in demand for individual vascular units. This would enable the concentration of

expertise and equipment as well as sustainable emergency on-call arrangements.

The medical specialty „vascular‟ refers to the treatment of conditions associated with blood vessels and

vascular services are for people with disorders of the arteries and veins. These include narrowing or

widening of arteries, blocked vessels and varicose veins, but not diseases of the heart and vessels in the

chest. These specialist vascular disorders were previously treated by surgery, however, specialists are

now able to treat many of these patients using interventional radiology; a much less invasive approach.

Making these advanced techniques readily available to all patients is one of the goals of the proposed

changes to vascular services.

Patients may use these services and access this type of surgery either as an emergency admission via an

A&E unit or as a planned, inpatient episode following referral from a GP or other specialist.

The proposed changes to vascular services have been included in the BHiB consultation process. In

addition to this, a separate engagement consultation has taken place on proposed changes to vascular

surgery services. This has involved the public and key stakeholders across the whole NHS South Central

region (Berkshire, Buckinghamshire, Oxfordshire, Hampshire and the Isle of Wight).85


Under the current profile of services, vascular surgery is currently provided at the John Radcliffe Hospital

(Oxford), Wycombe Hospital (High Wycombe), Wexham Park Hospital (Slough) and the Royal Berkshire

Hospital (Reading). Wycombe Hospital also currently provides specialist stroke care for patients through a

Hyper Acute Stroke Unit with 24/7 access to stroke consultants.

_________________________

83 This supplements an SHA level Strategic Equality Impact Assessment on the proposed changes to Vascular Surgery. See: NHS South Central Cardiovascular Network (July 2011) Strategic Equality Impact Assessment. Available from http://www.buckspct.nhs.uk/bhib/

84 Delivery of Vascular Surgery (Oct 2009) Tribal Avail

85 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg 42.

8. Vascular services

http://www.buckspct.nhs.uk/bhib/

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The John Radcliffe Hospital in Oxford provides emergency vascular care 24 hours a day, seven days a

week. The other hospitals each provide an emergency rota of one in four week days and one in four

weekends.86


In order to achieve the best possible outcomes for patients, it is proposed that complex vascular surgery is

undertaken at one Specialist Vascular Surgery Centre within the north of the South Central region, which

would provide 24 hour emergency and complex inpatient vascular surgery. Berkshire and Oxfordshire have

already agreed that a specialist vascular unit should be established at the John Radcliffe hospital, for the

following reasons:

The John Radcliffe Hospital is to be a major trauma centre and it will, therefore, be best placed to

undertake complex emergency surgery around the clock.

It already has a specialist vascular surgery team which can be built upon to provide a high quality

service for all vascular surgery patients in Thames Valley.

John Radcliffe is in a central geographical location.87

The proposals apply to the following vascular procedures:

Abdominal aortic aneurysms: This is a condition in which the main artery in the abdomen becomes

stretched and prone to bursting. Timely detection and treatment of abdominal aortic aneurysms

prevents later problems with rupture and bleeding, and can be lifesaving;

Strokes or transient ischaemic attacks (TIAs or mini-strokes): Sometimes, these problems with the

blood supply to the brain occur because of a narrowing in a blood vessel in the neck called the carotid

artery. This can be treated with an operation to improve the flow of blood and reduce the risk of future

strokes; and

Treatment for people with poor blood supply to the feet and legs: Some people, particularly those

who smoke or have diabetes, can develop narrowings in the blood supply to the legs and feet. This can

cause pain on walking, ulceration and infection. Surgical or interventional radiological treatment can

improve the blood supply, make walking easier and prevent the serious complications of inadequate

blood supply and lead to amputation.

For services in Buckinghamshire, there are two options for reconfiguration which are under consideration.

Option B has been identified as the preferred option in the consultation document. This option is set out

below. Details of Option A can be found in Appendix B.

_________________________

86 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg 44

87 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg30.

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8.1.2.1 Option B (preferred option)

Under Option B, the John Radcliffe Hospital in Oxfordshire would provide all emergency and elective

complex inpatient vascular surgery. However, operations to prevent strokes caused by carotid artery

disease (carotid endarterectomy or CEA) would continue to be provided at Wycombe Hospital for

Buckinghamshire patients. 88

This hospital currently provides the Hyper Acute Stroke Unit and would have

vascular surgeons undertaking operations to prevent further strokes.89

The option to continue to perform CEAs at Wycombe has been assessed by a national clinical assurance

team and a vascular expert panel. Both have suggested that this option might only be viable for a limited

period and would need to be reviewed in three years. The Consultation Document states that over this

period, John Radcliffe Hospital will continue to develop as a vascular centre, and stroke services will have

developed further at Wycombe Hospital. It therefore recommends that it may be beneficial to wait until

these services are embedded before reviewing the need to move CEA operations to John Radcliffe.

8.2 Health Impacts


As stated in the consultation document, medical evidence shows that the UK does not compare well with

other European countries for some vascular procedures. It has the highest mortality rates in Western

Europe following elective abdominal aortic aneurysm surgery and is among the slowest nations for uptake

of new endovascular technology, which allows some procedures to be undertaken by „keyhole‟ style

interventions which avoid the need for open surgery. Patients are not always treated by a vascular

specialist and stay longer in hospital following their surgery than the rest of Europe.90

Specialist services often use complex treatments for rare conditions. To achieve critical mass and enable

improved clinical quality, services should be concentrated and centralised. There is a robust evidence

base that risk-adjusted peri-operative mortality and long term conditional survival worsen as hospital

surgical volume decreases.91

A number of studies in recent decades have examined the relationship

between high-volume hospitals, long term survival and peri-operative mortality.92

93

94

Consolidation of case load to dedicated centres enables specialisation by both individual doctors and

the overall units, which has been shown to improve outcomes. The evidence suggests that

consolidation of vascular surgery and other specialist services leads to better clinical outcomes.

_________________________

88 Wycombe Hospital already provides vascular operation which prevent stroke from CEA. This will continue under the new proposed model of care.

89 It should be noted that this assumes that there is sufficient on site consultant time at Wycombe Hospital to provide a safe and effective service.

90 Goodwin, Nick (2010) Managing People with Long Term Conditions. Publication. London: Kings Fund

91 Karl Y. Bilimoria, David J. Bentrem, Joseph M. Feinglass, et al. Directing Surgical Quality Improvement Initiatives: Comparison of Perioperative Mortality and Long-Term Survival for Cancer Surgery, J Clin Oncol 26:4626-4633. 2008

92 Luft HS, Bunker JP, Enthoven AC, Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 301:1364-1369, 1979

93 Halm EA, Lee C, Chassin MR, Is volume related to outcome in health care? A systematic review and methodological critique of the literature. Ann Intern Med 137:511-520, 2002

94 Fong Y, Gonen M, Rubin D, et al, Long-term survival is superior after resection for cancer in high-volume centres. Ann Surg 242:540-544, 2005; discussion 544-547

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Numerous studies have demonstrated better results at high-volume hospitals with cardiovascular

surgery, and other high-risk procedures.95

96

97

In some hospitals, there is insufficient critical mass of patient workload to justify consultant presence to

provide 24/7 service and maintain high quality care and outcomes for patients. Therefore, under the

proposed reconfiguration, specialists will be concentrated in fewer hospitals, ensuring that patients receive

the treatment needed on a timely basis. In particular, the reconfiguration will also address issues in

accessing interventional radiology services; creating 24/7 interventional radiology rotas. There is

also evidence which suggests that centralising specialist services can drive quality through a

“physician/surgeon” effect. At a specialist centre, physicians and surgeons will see more of a particular

diagnosis or perform a greater number of specific procedures, which can lead to the achievement

of higher quality outcomes for patients.98

99

Given the evidence that specialisation and centralisation can drive quality outcomes, there is a strong case

based on quality for change in service provision in the sector towards consolidation of skills and case-load

in fewer centres with greater patient volumes. There is also evidence that suggests that consolidated

vascular services can be more economically efficient (an “economy of scale” effect). A recent report

by the Vascular Society identified that the provision of an effective vascular service is relatively expensive

as the surgery is technically demanding with significant demands on both theatre and critical care time;

centres can have high bed occupancies and some patients may need prolonged hospital stay particularly

where rehabilitation and community services are not readily available. It therefore concludes that

“replicating these services in every hospital is not cost effective and this must be balanced against issues

of equality of patient access and aspirations for a local service”.100

The impact assessment therefore considers that the reconfiguration proposals for specialist vascular

surgical services would enable these benefits to be delivered, thereby leading to a positive impact upon the

health outcomes and care experience of people living in the affected areas.


There is much evidence available on the risk factors for vascular disease. These include101

102

:

Age: Evidence suggests that the prevalence of vascular disease increases with age. The complexity,

outcome and costs of vascular intervention are also age-dependent. This is discussed further in section

8.3.1 below.

_________________________

95 Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979;301:1364-9.

96 Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280:1747-51.

97 Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high volume hospitals: estimating potentially avoidable deaths. JAMA 2000;283:1159-66.

98 Hannan EL, Popp AJ, Tranmer B, Feustel P, Waldman J, Shah D. Relationship between provider volume and mortality for carotid endarterectomies in New York State. Stroke 1998;29:2292-7.

99 Hannan EL, Siu AL, Kumar D, Kilburn H Jr, Chassin MR. The decline in coronary artery bypass graft surgery mortality in New York State: the role of surgeon volume. JAMA 1995;273:209-13.

100 The Vascular Society of Great Britain and Ireland (2012) The Provision of Services for Patients with Vascular Disease

101 The Vascular Society of Great Britain and Ireland (2012) The Provision of Services for Patients with Vascular Disease

102 NHS Buckinghamshire and Buckinghamshire County Council (2010, updated 2011) Joint Strategic Needs Assessment

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Prevalence of diabetes: Over 40% of patients admitted under the care of the vascular team have

diabetes and vascular disease is the major cause of morbidity in diabetes and the risks of disease

progression are higher. Lack of exercise, poor diet and increasing age are all associated with an

increasing incidence of Type 2 diabetes. Whilst Buckinghamshire is in the 10% of PCTs with the lowest

prevalence of diabetes in England, the prevalence of diabetes (Type 1 and 2) in Buckinghamshire is

predicted to increase from 2009 prevalence rates of 4.4% to 6% by 2025.

Smoking: This is a major cause of vascular disease and over 80% of vascular patients are current or

ex- smokers. Smokers are at greater risk of complications from vascular interventions because of

cardiac and respiratory co-morbidity; in addition, the longer-term success of vascular intervention is

reduced in patients who continue to smoke. Across Buckinghamshire, it is reported that 14-18% of

adults smoke. This is lower than most comparable PCTs and the national average of 21%.

Geography: There are variations in the prevalence of vascular disease between different parts of the

country although the reasons for this are complex and poorly understood, but include genetic

influences, diet, social class, age and possibly climate. These factors introduce geographical variation in

the demands for vascular services. Popular retirement areas are places of high demand on vascular

services as they have relatively higher proportions of elderly patients.

Using information from the Vascular Society of Great Britain and Ireland103

and 2013 population estimates

for Buckinghamshire104

, it is possible to estimate that every year the Buckinghamshire population will

produce, approximately:

365 arterial operations;

245 interventional radiology procedures; and

422 venous operations.

The regional Impact Assessment undertaken at SHA level also provides a further estimate of the number of

required vascular procedures in accordance with 2013 population figures. This is outlined below.

Figure 8.1: Predicted number of vascular procedures based on 2013 population figures

Source: NHS South Central Cardiovascular Network (July 2011) Strategic Equality Impact Assessment

_________________________

103 The Royal College of Radiologists and the Vascular Society of Great Britain and Ireland (2003) Provision of Vascular

Radiology Services..

104 Buckinghamshire population of 521,100 in 2013. Source: Tribal Avail (2009) Demand and Capacity Report

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The Consultation Document provides some information on the number of services and procedures

undertaken by each site in 2010, as illustrated below.

Table 8.1: Procedures undertaken in 2010

Emergency aortic aneurysm

repairs

Planned aneurysm

repairs

Bypass of arteries in the

groin

Major amputations

Carotid endarter-

ectomies (CEA)

John Radcliffe 27 101 (39 by ECAR)

74 44 90

Wycombe 8 34 (27 by ECAR)

50 13 86

Wexham Park 4 19 (14 by ECAR)

60 51 30

Royal Berkshire 2 17 (11 by ECAR)

26 41 10

Of the 191 patients currently receiving treatment at Wycombe, 105 will receive treatment in the future at the

John Radcliffe Hospital and 86 patients (45%) will continue to receive treatment at Wycombe Hospital for

CEAs.


This section provides evidence to highlight which equality groups are likely to have a high need for

specialised vascular services. For each of these „screened-in‟ groups potential positive and negative effects

of the proposals are then discussed.

8.3.1 Older people

The connection between vascular care and age is well documented. The Vascular Society of Great Britain

and Ireland National Vascular Database Report for 2009 clearly outlines the extent to which the need for all

major complex vascular surgeries increases with age, being particularly prominent in the over-60s and 70s.

The age of patients undergoing surgery for abdominal aortic aneurism rises sharply from 60 onwards,

being highest in the 70-79 age bracket.

This pattern is repeated for infrainguinal bypass surgery and those undergoing amputation.105

Underlying

common factors of long-standing vascular disease and age include blood pressure, obesity, diabetes and

other conditions – all of which are factors and all tend to cause more problems over time.

The shift of the small number of emergency and elective complex inpatient vascular care to John Radcliffe

Hospital in Oxford will result in longer journey times for older people from most parts of the county, and

particularly those currently in close proximity to existing provision. See Figure A.2 in Appendix B for more

details. However, the benefits of retaining CEA services, as well as outpatients and diagnostics, at

Wycombe are important to stress, especially as the only other proposed option for vascular care would

have involved the transfer of these to Oxford too.

_________________________

105 Vascular Society of Great Britain and Ireland (2009) : „The National Vascular Database Report 2009‟, p.32,53,66

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8.3.2 BAME groups

In common with above, as health issues such as high blood pressure, obesity, diabetes and other

conditions which are common factors in long-standing vascular disease are more common in some BAME

groups, then they also have a higher need for complex vascular surgery.

As with older people the large number of people from BAME groups located in the south of the borough will

already be seeing greater availability of those services to be located at Wycombe Hospital. However, as

with older people, the shift to Oxford John Radcliffe Hospital for certain services may mean longer journey

times for the small numbers of BAME people, particularly those in the south east and north who require

complex or emergency vascular care. See Figure A.5 in Appendix A for more details.

8.3.3 Disabled people

It was outlined in section 5.3.3 above that there is proportionally high demand for some inpatient services

from people with learning disabilities. The same is true in terms of complex vascular care, due to the

propensity of people with these conditions to experience heart disease. Evidence shows that coronary

heart disease is the second highest cause of death for people with learning disabilities. People with

learning disabilities are more likely to develop hypertension and obesity and lack exercise, all of which are

risk factors for ischaemic heart disease. People with Down‟s syndrome are particularly at risk of congenital

heart problems.106

Again, whilst number of people in this protected group may be small, given the high propensity for those

with learning difficulties to need the above services, they are a group which could well experience

disproportionate impacts. In developing and implementing mitigation measures, this group and, where

relevant, their carers will need to be considered.


There is convincing evidence to suggest that people from deprived communities have a high susceptibility

to conditions requiring vascular care. For example, there are marked inequalities in smoking rates between

the most affluent (who smoke least) and the least affluent (who are most likely to smoke).107

Smoking is

one of the major causes of cardiovascular diseases, including coronary heart disease. According to the

British Heart Foundation, smokers are almost twice as likely to have a heart attack as those who have

never smoked.108

Obesity, which is associated with cardio-vascular disease, stroke and diabetes, is also a frequent condition

amongst poorer demographic groups; this is partly because residents have less financial freedom with their

food shopping and more limited access to physical activity at safe recreational spaces or leisure centres.109

Sport England suggests that of those that regularly participate in active recreation only 15% are from the

lowest socio-economic groups compared with 26% from the highest.110

_________________________ 106

Royal College of Nursing (2011): Op. cit.

107 Mayor of London (2007): Op. cit.

108 See: http://www.bhf.org.uk/keeping_your_heart_healthy/preventing_heart_disease/smoking.aspx

109 Mayor of London (2007): Op. cit.

110 Sport England – quoted in Mayor of London (2007): Op. cit.

http://www.bhf.org.uk/keeping_your_heart_healthy/preventing_heart_disease/smoking.aspx

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As with other services, the low levels of deprivation in the county mean that the likely impact on deprived

communities of the change to vascular services is small. People from the small pockets of deprivation in

Aylesbury and High Wycombe are likely to experience longer journey times when accessing emergency

and elective complex inpatient procedures at the John Radcliffe Hospital in Oxford, but numbers are

relatively small and, as such, disproportionate negative impacts for this groups are not expected. See

Figure A.6 in Appendix A for more details.

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Chapters 4 – 8 present impacts which are specific to each of the services under review as part of the BHiB

programme. This final chapter presents the overall conclusions of the impact assessment; that is impacts

which apply to all or most services within the BHiB review. It draws out the positive and negative impacts

that are considered to be experienced as a result of the implementation of the proposals. In addition it

presents recommendations regarding enhancement of the positive impacts and mitigation of the negative

impacts.

9.1 Potential positive impacts

The proposals have the potential to deliver a number of significant positive impacts for the population of

Buckinghamshire. These are:

improved clinical outcomes and maximised health benefits;

improved quality of care and patient experience;

improved delivery of sub-specialist care for those requiring acute care for their long term conditions; and

access to more community-based care.

Many of these positive health impacts would be of particular advantage to people from equality groups, in

particular older people, people from BAME groups and those living in deprived areas. This is because

people from these groups are more likely to require the services under review due to their propensity to

experience certain health conditions. In the case of older people in particular, and to some extent deprived

communities who are less likely to have access to private transport, these residents are also most likely to

benefit from care closer to home, which prevents the need to travel to receive treatment from suitable

experts.

9.1.1 Improved health and clinical outcomes

The assessment considers that the most significant impact resulting from implementation of the

reconfiguration proposals would be improved health and clinical outcomes for people accessing the

services under consideration.

The proposals have been developed based upon the underlying principle of enabling clinical services to be

delivered in the most appropriate setting. This includes not only ensuring that certain specialities are

consolidated onto one site to maintain a critical mass and consistency of practice, but also the delivery of

services at home or closer to home, where appropriate, to limit the need for hospital admission.

The assessment considers that this underlying principle would improve clinical outcomes for the population

of Buckinghamshire through:

Providing care closer to home, which would help to reduce the affect of long and inconvenient travel

times. As detailed above, this is a particular benefit for those from certain equality groups who are

reliant on public transport and/or have difficulty travelling independently. Older people and those from

deprived communities fall into this category.

9. Overall impact of proposals

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Enabling clinical services to more closely meet the needs of patients. A good example of this can

be seen in the proposals for A&E and urgent care services. For example, the A&E at Stoke Mandeville

Hospital would be equipped and resourced to assess, treat and manage clinical emergencies, whereas

less-critical cases could be treated at the minor injury and illness unit at Wycombe Hospital. This

process of streaming would decrease the different stages of a patient‟s experience and the number of

practitioners they have to deal with. Women using breast services at Wycombe Hospital will also

experience these benefits.

9.1.2 Improved quality of care

The assessment considers that there would be an impact on the quality of care resulting from

implementation of the reconfiguration proposals. The creation of specialist centres and the work

undertaken on patient pathways to ensure the appropriateness of care (including avoiding unnecessary

admissions) will ensure that patients are able to access services and competent clinical decision makers in

a timely manner and will receive the benefits of continuity of care from a specialist team; improving the

quality of the services they receive and the experience of patients.

In addition, the creation of Centres of Excellence, such as for breast assessment will provide access to an

experienced and specialised multi-disciplinary team who through co-location are better able to share

expertise and best practice across the team, improving care and patient outcomes and also contributing

to the morale and retention of staff.

9.1.3 Access to more specialist care

As part of the overarching impact of improved clinical outcomes and health benefits the assessment

considers that the reconfiguration proposals would enable the residents of Buckinghamshire to have

greater to access to specialist care. This would be achieved through the consolidation of certain services

onto fewer sites thereby ensuring the development of highly skilled and effective clinical teams delivering

the most current clinical practices with state of the art technology. This specialisation would ensure that

care is consistent and continuously improving.

9.1.4 Benefits of more community-based care

The vast majority of patient hospital visits are to outpatient appointments. Under the reconfiguration

proposals, outpatients appointments will largely remain being provided on the same site as they are

presently. The exception to this would be for breast care, where all first outpatients will also attend the

Centre of Excellence at Wycombe Hospital. It should be noted, however, that longer travelling distances

and/or times for outpatient appointments are likely to be outweighed by the level of service provided at the

specialist Centre.

Although the proposals entail some additional travelling time to access acute inpatient services, there is

good evidence to suggest that investment in more community based care reduces the need for

attendance and/or admission to hospital for outpatients and others who do not require acute provision,

for example day assessment services and GP access to expert advice to support the elderly. Community

services will also enable care for people in their own. These factors should help to limit those needing

to travel long distances for treatment.

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Provision of care at home would bring with it considerable benefits, particularly for some sections of

Buckinghamshire‟s population. For example, of the different equality groups likely to be disproportionately

affected, BAME communities, older people and those from deprived communities are likely to reap

rewards from the transition to more community-based health services. They tend to have higher

levels of morbidity especially from long term conditions (LTCs), and it is these LTCs that are best managed

in local community-based services.111

These equality groups would benefit more from preventive services

which would be delivered in the community, which, in turn, could reduce the development of acute

conditions and the consequent need for urgent treatment and admission to hospital. Finally care closer to

home reduces the need to travel. This is a key issue with regard to many equality groups, as older people

and those from BAME groups can feel more vulnerable when travelling outside of their local communities,

due to mobility problems, communication, safety or cultural issues. Community service delivery could

also be beneficial to people without access to their own transport, thereby benefiting those on

lower incomes in socially deprived groups.

9.1.5 Benefits for NHS staff

In addition to the anticipated improvements in clinical outcomes for patients mentioned above, a number of

key benefits for staff would also be derived. These benefits would be:

Staff with similar specialist skills better able to create sustainable teams;

Improved multidisciplinary and multi-sector team working;

The development of new ways of working and job roles; and

Improved working practice arrangements and rotas for current medical staff leading to higher levels of

retention and the future recruitment of high quality staff..

9.2 Opportunities

For each positive impact the assessment process has sought to recommend ways in which the impact may

be enhanced to deliver greater benefits.

9.2.1 Implementation

To ensure the full realisation of the above positive impacts, it is important that the assumptions

underpinning the achievement of improved clinical outcomes are themselves achieved. There is an

essential role for clinical staff in planning and facilitating the changes in the working practices that will be

required. In particular, continued close joint working will be necessary between hospital specialists,

GPs and other primary care professionals if reductions in inpatient admissions are to be delivered

and future service provision can be fully sustainable.

In addition to the need for implementation to be clinically led, it is also essential that the implementation is

supported by a robust strategic plan. This plan would address the following key issues:

Careful specification of how key milestones are to be achieved in a sustainable way. This would

include consideration of appropriate phasing of the proposal elements and the roll out of urgent care

services and community-based services across the sector.

Identification of how any commissioning challenges are to be tackled and how cross-

organisational working would be supported and incentivised.

_________________________ 111

Royal College of General Practitioners (2011) Care Planning: Improving the Lives of People with Long Term Conditions

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Identification of a transparent change management process to ensure that changes in practice are

understood owned and sustained. This would include the identification of a process for sharing good

practice and ongoing evaluation of clinical outcomes to enable the impact of the proposals to be

measured and assessed over time.

The extent to which outcomes will be improved should be scrutinised and monitored to ensure

that reconfiguration delivers the expected improvements. Evaluation of changes or new services is good

practice in public policy delivery across all sectors and is often an effective way of capturing successes

and communicating those to stakeholders.

9.2.2 Communication

One of the most effective ways in which to make reconfiguration more effective would be to ensure that the

new arrangements are well communicated to the local population. Whilst there has been a formal

consultation process undertaken to outline and seek views on the proposed changes, it is important and

necessary for the communication of the changes to be a sustained activity that continues beyond

initial implementation of changes. Reconfiguration is unlikely to be instantly understood so educational

activities will need to develop awareness gradually. Indeed, the consultation documents states that

during the engagement phase, people stated that they were unclear about where to get appropriate

treatment.112

The reconfiguration’s success will be somewhat dependent on Buckinghamshire on

clarity about services on offer at each site and residents knowing where to present. There needs to

be a consistent effort that clearly explains who needs to go where and for which services. Terms such as

„minor injury and illness‟; „step-up‟; „step down‟; „complex‟; „urgent‟; and „acute‟ will need defining and

reinforcing to avoid any future confusion.

As well as where to present, communication also needs to further demonstrate the rationale behind

and review and the benefits to people’s health, wellbeing and clinical outcomes as a result of the

changes. The fact that the vast majority of initial NHS contacts from patients will remain as they now,

through primary care and outpatients at local sites also needs to be stressed.

It is suggested that communication should take a variety of forms (e.g. Council and other advice

centres; online; leaflets; press articles; through local community groups and voluntary associations; and

directly by the NHS to its staff, primary care and to local authority staff). There is also an opportunity, to

target particular equality groups. Benefits could also be achieved through education and awareness

raising amongst more vulnerable communities, for example, with primary care and social care staff

providing targeted patient information on the benefits of GP attendance and preventive care in helping to

avoid emergency admissions.

_________________________ 112

Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg32.

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9.3 Potential negative impacts

The proposals have the potential to deliver a number of negative impacts for the population of

Buckinghamshire. These are:

Confusion amongst the population about how to access services in the future;

Split in service delivery between acute and step down care for general medical and elderly care across

sites;

Clinical inter-dependencies;

Reduced ease of access in certain areas;

Pressure upon existing capacity; and

Reduced patient choice.

9.3.1 Confusion amongst the population about how to access services in the future

Elements of the reconfiguration proposals mean that patients will need to use different hospitals for

different services. This reality creates one of the most significant potential negative impacts of these

proposals – the possibility of confusion on the part of residents about how to access the health care

services that they need. The issue includes not only where patients should go for certain services, but

also how they should access them – via a minor injury and illness unit, their GP, or the hospitals – and

when they can be accessed – 24 hours a day or just during office hours.

Although some confusion may already exist within the current configuration, this could be exacerbated by

the proposed configuration of services. For example, people will need to be aware of the differences

between the care that could be expected at an A&E, a minor injury and illness unit, a local GP clinic or

practice.

The main risk of this confusion is that emergency cases could present at the minor injury and illness

unit resulting in a need for transfer to a more appropriate site. This would lead to a delay to treatment

with potential serious impacts upon the clinical outcome. This could also result in the disruption of the

quality of care for those patients requiring transferral.

There could be particular difficulties for certain equality groups, for example those for whom English

is not their first language, older people or those with hidden disabilities. It may be a challenge for some

people within these groups to comprehend and/or accept reconfiguration due to an inherent trust they

already have in A&E, Emergency Medical Centre and GP services as opposed to a minor injury and illness

unit which form part of a new medical vocabulary.113

_________________________ 113

Some of these challenges around presentation were also identified in the NCAT review and BHiB has undertaken work to ensure that where patients do present at an inappropriate setting, they will still receive safe care. Through the expert review undertaken by NCAT, the issue of patients with stroke mimics or psychogenic presentations, who present at Wycombe Hospital, but do not have a stroke (which can be as much as 50% of those presenting) was discussed. The NCAT report states that in response to this, there will be a facility to admit some of these patients to Wycombe Hospital where they can be monitored, if need be over night, and to take the advice of the medical team based at Stoke Mandeville in case transfer was needed. There would also be available on-site diagnostics such as simple biochemistry and full blood count, to ensure these patients were not physiologically compromised and requiring other acute interventions. See: National Clinical Advisory Team (10 October 2011) Review of BHiB reconfiguration plans p10

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9.3.2 Split in service delivery between acute and step down care for general

medical and elderly care across sites

Whilst the proposals aim to centralise services and reduce fragmentation in care pathways, for some

services (general and elderly medicine) there could be impacts for patients given the split in service

delivery between the sites. For example, under the reconfiguration proposals discharge from Stoke

Mandeville Hospital or other neighbouring hospital may mean referral to Wycombe Hospital for step down

care. This would require a transfer between sites and better close working between the hospitals would be

needed for effective discharge, transfers and rehabilitation.

More complicated discharge arrangements, could also give rise to resource implications for community and

voluntary organisations, which often play an important role in transfer and discharge. Many of these not-for-

profit organisations already experience intense pressure on resources available to them and this may be

further exacerbated by the reconfiguration proposals.

9.3.3 Clinical inter-dependencies

The NCAT review identified that the future viability of critical care services at Wycombe Hospital could be

challenged if vascular services are not provided in the future; impacting on the future sustainability of

cardiac and stroke services on the Wycombe site. The sustainability and affordability of the acute stroke

and cardiac at Wycombe Hospital is likely to be dependent on the outcome of the vascular surgery review.

However, BHiB have reported that NCAT are satisfied that the provision of critical care had been

thoroughly considered in relation to clinical quality and standard; as well as the economic impact of

providing two units. The unit at Wycombe will therefore be run as a satellite unit to the main critical care

unit at Stoke Mandeville. BHiB further comment that “even without vascular surgery, critical care services

will be sustainable as the main users of the unit are acute stroke, stroke mimics, cardiac patients and

complex elective surgery (only some of which is vascular)”.114

To mitigate against this negative risk and to ensure that reconfigured critical care services are implemented

effectively, a critical care clinical sub-group has already been established, reporting to the Clinical Strategy

Group and on to the Programme Board.

9.3.4 Reduced ease of access in certain areas

The centralisation of services from two to one hospital sites, inevitably means that some people will be

required to travel further to access certain services. During the engagement process that BHiB

undertook during the development of the reconfiguration proposals, transport was highlighted as a key

issue around which people have concerns. It is clear that some inpatients will have increased travel times

to reach the services that they need. The transport assessment commissioned by Buckinghamshire

Healthcare NHS Trust looked at the impact of the proposals on kilometres travelled by in patients,

concluding that overall there would be a net increase of 14,888km per year.

_________________________

114 Better Healthcare in Bucks: Response to the NCAT Report, November 2011

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Adverse impact on outpatients are expected to be negligible given the concentration of the BHiB proposals

on inpatient services. There will, however, be effects for families and friends wishing to visit those receiving

inpatient care, The transport assessment acknowledged these impacts and calculated that they would add

a further 29,777km to distances travelled; combined with inpatient effects the overall net increase is

therefore likely to be in the region of 44,663km per year.115

116

Increasing the distance needing to be travelled is likely to affect certain sections of the population

more than others. Inpatients needing to travel for acute treatment will, more then likely be transported by

ambulance. However visitors will be affected by the proposed changes. The new service configuration will

particularly impact upon those who are reliant on public transport because journeys will not only be new,

but they are also likely to be more complex involving more than one or changes and/or more than one

mode of transport. Increased travelling times and distances are also likely to affect visitors from some

equality groups more than other members of the general public. Many of society‟s more vulnerable

populations (women, younger people, older people, BAME groups, disabled people and people from

deprived communities) have a higher than average reliance on public transport and are less likely to have a

driving licence or access to a car. Additionally, older people tend to have well established travel routines

which may be disrupted or require alteration, thereby reducing confidence about travelling alone to new

sites whether by car or public transport. In the same way, some BAME and faith groups can find travelling

beyond their local area or using different routes daunting, either due to limited language capabilities or

feeling safer in the environment of their more immediate community.

In terms of the geographical distribution of these impacts, the population in the south of the county

around High Wycombe will be affected more than that in the north as, under the BHiB preferred

option, most services under review will be located at Stoke Mandeville rather than Wycombe.

It should be noted, however, that these travel impacts will affect very few patients as, according to

patient activity modelling presented in the consultation document, only 1,700 patients in total who currently

use Stoke Mandeville (0.5% of the hospital‟s total patient caseload) will need to use Wycombe in future,

whilst 7,600 patients (3% of the hospital‟s caseload) who currently use Wycombe would need to use Stoke

Mandeville in future. In addition the majority of these will be taken hospital by ambulance.

Understanding that transport and access are key issues, BHiB has already established a transport

subgroup to ensure that the transport implication so the proposals are being fully taken into

account. Potential mitigation measures are in development, including:117

Improvements in car parking arrangements at the hospitals;

The use of telemedicine to save patients having to travel to a specialist;

Provision of better travel information; and

Working with Arriva buses and other public transport operators to improve public transport to hospital

sites for patients, visitors and staff.

_________________________ 115

COTTEE Highway and Transportation Consultants (2012): „Better Healthcare in Buckinghamshire: Transport Statement April 2012‟ 116

The assessment was based on car journeys only it is likely to be an underestimate. The assessment also did not consider travel times for patients, which provides a more useful indication of actual impacts on both patients and visitors; the actual time taken to access a site is more relevant in terms of accessibility as well as the psychological and convenience impacts on patients‟ and visitors‟.

117 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg 36

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The subgroup is also working on plans for transfer of patients between sites, visitors and staff between

sites.

Once the service model for the minor injuries and illness has been agreed, the ambulance service will be

able to assess the impact the proposed changes on its service.

9.3.5 Pressure upon existing capacity

Inevitably the transfer of certain services would result in an increase in demand and the volume of activity

at sites; particularly Stoke Mandeville Hospital which is expected to need to accommodate 7,600 more

patients per year. This could result in extra pressure in the short term on already busy units resulting

in such effects as extended lengths of stay, cancellation of procedures and extended waiting times.

Work is being undertaken to accommodate additional demand at Stoke Mandeville Hospital and there are

proposals for developments in community services and the step down facility at Wycombe hospital.

However, if these community service developments are delayed in their implementation and/or are pulled

into meeting unmet demand in the community this may create bed blockages at Stoke Mandeville hospital.

This could be further exacerbated if there are delays in discharging patients from the step down facility at

Wycombe hospital.

Ambulance services also could potentially experience increased strain, having to cope with

transfers of people who have presented to the ‘wrong’ site or being required to transport patients to

a site which is further away. In addition, where patients call an ambulance, the ambulance service would

need to ensure the patient is taken to the most appropriate hospital, not necessarily the nearest. This

requires not only full understanding of the patient‟s conditions and the acute services at each site, but it

could also place strains on ambulance service capacity. Analysis has been undertaken with the Ambulance

Service to map the impact on ambulance journeys. It is estimated that 31% of current ambulance journeys

currently going to Wycombe Hospital would travel to alternative acute providers following implementation of

BHiB.118

Of these journeys, 50% will be directed to Stoke Mandeville, 43% to Wexham Park, 5% to

Watford, with the remainder travelling to Watford or Oxford‟ It should be noted, however, that the

consultation document reflects the involvement of the ambulance service during the developments of the

proposed configurations so as to minimise these risks.119

9.3.6 Reduction in patient choice

The principle of patient choice is key to the development of high quality healthcare services and is regarded

as a right that should be exercised. Typically, when the configuration of service provision is changed, users

express anxiety about how they perceive these changes with impact upon the status quo and their care

experience.

_________________________

118 ‟This represents 2,637 ambulance journeys from the 8,440 journeys currently going to Wycombe Hospital.

119 Proposals to change and improve NHS services: Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire. Pg36

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Whilst it was generally acknowledged that the proposed changes would allow the highest level of expertise,

safety and clinical outcomes to be provided to patients, these benefits could be at the expense of

patient choice where services were consolidated onto fewer sites. This could be a disadvantage to some

equality groups, who take comfort in attending their nearest hospital for reasons of familiarity or ease of

access. Of course, patient choice is a less relevant consideration when considering emergency admissions

via blue light ambulance; which may be the case for many requiring admission to acute medicine services

at the Stoke Mandeville hospital site.120

9.4 Mitigations

This section discusses potential ways in which to mitigate or reduce the effect of the negative impacts

identified above.

9.4.1 Transfer protocols and communication

Good communication between hospitals will be essential to reduce the effect that may be caused by

inappropriate presentations and more fragmented pathways of care; protocols need to be put in place to

ensure the effective transfer, which minimises stress and anxiety for patients and their relatives. Many

examples of good practice exist and the learning from other organisations can be used to enable

successful mitigation strategies. This could also include the learning developed from the reconfiguration of

stroke and trauma services locally. There needs to be good communication and cross site working to

support those patients with complex co-morbidities i.e. those cardiac patients who also suffer chronic

diseases. Under the proposals, these services will be split across the two sites, which could fragment care,

cause delays and affect outcomes.

BHiB have stated that clear protocols are already in place and some of this work has already been

considered and in response to the NCAT review. The health community has stated that if patients admitted

to Stoke Mandeville Hospital develop an unexpected stroke, advice will be sought from the acute stroke

physicians at Wycombe Hospital who will either provide advice or visit the patient. Similar solutions will

need to be sought at Wycombe Hospital to provide specialist medicine support to patients admitted there

with acute coronary syndromes and acute strokes who have other medical problems. During working

hours, there may be visiting physicians on site.

9.4.2 Discharge protocols hospital to hospital/community

Standards of patient after-care must be maintained, regardless of the distance between a patient‟s

treatment location and their place of residence. To ensure that patients do not experience fragmentation of

care, the development of integrated delivery pathways involving all of the services responsible for caring for

the well being of patients (including social services) would be required. This will involve the establishment

of protocols for patient transfer, discharge and rehabilitation during both the transitional phase and

following full implementation.

_________________________

120 Modelling undertaken by BHiB estimates that there will be additional 1,318 ambulance journeys to Stoke Mandeville Hospital.

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It is considered that the following steps will be required:

Proactive management of patients through the inpatient pathway, in line with best practice, to ensure

that they can be transferred back to a local hospital and/or community rehabilitation facility. This would

minimise the period of time spent in an acute hospital and the need for family and friends to travel long

distances to visit; and

Integrated working between hospitals and the community, with involvement of social services.

9.4.3 Options to mitigate access impacts

As noted above, we understand from the consultation document that a transport subgroup has been

established comprising membership of Buckinghamshire County Council, South Central Ambulance

Service and the Trust. This subgroup is already working on several mitigation strategies; other suggestions

which this group may wish to explore to minimise any adverse effects in terms of transport and accessibility

are set out below:

Providing useful travel information – the transport subgroup is already working on improving the

provision of travel information. It should be ensured that this is available on hospital websites and at the

hospitals themselves for both private and public modes of transport. Information should be in formats

accessible to disabled people and those who do not speak English as their first language to ensure that

any inequalities are addressed. This will be important to both patients and visitors. Travel information

should be displayed in prominent positions, such as reception areas or waiting rooms and there is an

opportunity to send details to patients together with their outpatient or admission appointments ensuring

that NHS staff are aware of travel and access requirements – including financial assistance where

appropriate – in advance of the patient‟s journey.

Pedestrian way finding - Public way finding to each hospital needs to be provided at nearby bus stops,

underground stations and railway stations to help people access hospitals; this would be especially

useful for those having to use a different and less familiar hospital as a result of the new arrangements.

Working with public transport providers could help to secure this. Way finding should not be limited to

English and needs to be provided in other languages relevant to the population of the wider area and

patient demographic profile.

Travel plans – There should be in place high quality travel plans, which take into consideration the

needs of patients, visitors and staff. These travel plans need to be developed in conjunction with the

transport providers and other local stakeholders. The travel plans should focus upon segments of the

population with the longest travel times and those who are likely to face particular challenges in

accessing care, including equality groups. Staff transport schemes, particularly where staff need to

travel between sites or where shift patterns often result in very late finishes or very early morning starts

could be included, as well as subsidised travel for people travelling longer distances or from deprived

areas; and

Securing good access by bus - In the long term it would be beneficial to work to ensure that both sites

are served by accessible buses. There is already a free shuttle bus between the two sites; it would be

worth reviewing service frequencies and timings. Ensuring stops are clean, well maintained and well lit,

as well as fully accessibly for disabled people, will also serve to improve the experience of users

travelling by bus. This is an option which will be particularly beneficial to both visitors and staff.

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9.4.4 Maximising potential capacity

A number of measures would ensure that existing capacity is utilised more efficiently and that additional

capacity is accessed. These measures include: the redesign of operational and clinical processes to

improve patient flow and demand management including the development of new ways of working and new

roles; and the introduction of standardised, evidence based pathways of care to enable optimal length of

stay for high volume conditions and long term, chronic conditions to ensure that inappropriate admissions

are avoided. These models may include specialist nurse led clinics provided in community settings or self

management programmes.

We recognise that the health community has acknowledged the need to change its working practices and

to date has been working hard to develop a system of vertical integration of healthcare through from

primary care to the community hospitals and to the secondary care hospitals. It recognises that the biggest

changes will be within the medicine for older people speciality with the move towards greater community

based service delivery and the Trust has stated that physicians have been working with community teams

and GPs to develop this service provision.

Any new ways of working should be implemented in a systematic and planned manner to ensure that the

whole healthcare system benefits from the required changes and to reduce inconsistency of service.

9.4.5 Patient choice

Although the reconfiguration proposals would marginally reduce the choice that the residents of

Buckinghamshire would have for breast assessment services, this would be outweighed by the positive

impact of improved clinical outcomes. However, often there is anxiety created by the knowledge that they

may have to access a hospital site that they would not usually choose, or indeed would positively avoid,

leading to a feeling of negativity.

Effective communication as to why the concentration of services is taking place and where choice

remains would be key to reducing user anxiety and to avoiding any patient frustration about the

need to use a certain hospital for certain treatment.

It is considered that the benefits of a better care experience and improved clinical outcome, if well

explained, would materially decrease concerns on this point. As most patient experience begins in the

community, GPs and primary care services would have a crucial role to play in making sure that this

communication effort is implemented and sustained.

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Overall, the findings of the assessment suggest that the reconfiguration proposals would have the potential

to bring considerable benefit to the population of Buckinghamshire in terms of improved health, wellbeing

and clinical outcomes following the treatment for urgent and complex conditions. The realisation of these

benefits would result in some trade offs, particularly in terms of increases to the time people would need to

spend travelling for hospital treatment. However, these trade offs are relatively limited compared to the

proposals‟ benefits. In addition, they would also only be experienced by the small proportion of the

population who require access to the services under review (as outlined in chapter 4 to 8).

10.1 Key findings – individual service areas

The table below sets out the key impacts by service area and also highlight which equality groups out of

the nine protected characteristics are most likely to experience impacts.121

The table focuses on those

equality groups which are expected to experience disproportionate impacts (that is, over and above

the population in general).

_________________________ 121

The nine protected characteristics (or equality under the Equality Act (2010): age; disability; gender reassignment; pregnancy and maternity; race; religion; sex; sexual orientation; and marriage and civil partnership. The EqIA considered all of these in the screening exercise and then „screened in‟ those groups that are likely to have a higher propensity to experience certain conditions and, therefore, the services under review. This was done on a service-by-service basis. The role of an EqIA is to focus on those groups who are likely to experience different (i.e. type of impact) and disproportionate (i.e. to a greater extent) impacts – not groups who are likely to experience the same impacts as the general population or no impact at all.

10. Conclusions and recommendations

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Table 10.1: BHiB – service specific impacts


Emergency Care Concentration of expertise at Stoke Mandeville will enable the hospital to offer the full range of complex emergency presentations and achieve better outcomes. Admissions will be appropriate with decreased lengths of stay and fewer onward specialist referrals.

Minor injuries/illness service to be developed at Wycombe Hospital.

Day assessment unit for frail (usually) elderly people.

Older people, BAME groups and deprived communities are the equality groups most susceptible to requiring emergency care service. It is expected, however, for the numbers experiencing these negative impacts to be very small because many patients (up to two thirds)122 will be able to receive treatment at the minor injury and illness service based at Wycombe. In addition some of the more serious injuries experienced by these groups will be treated at the major trauma centre at Stoke Mandeville, which is the same as at present. This should help to offset disproportionate impacts.


Ambulance protocols to convey emergency patients to the appropriate site.

Protocols to manage patient transfers between sites if required.

Partnership working between services to manage patients locally and avoid unnecessary presentations at A&E, e.g. SCAS and the adult community team working with the falls team to manage in the community patients who have fallen.


_________________________ 122

This assumption is based on analysis of the numbers of patients attending the Wycombe Emergency Medical Centre in 2010. See Consultation Document (16 January to 16 April 2012) Better Healthcare in Buckinghamshire p. 13.

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The proposals present an opportunity to provide sufficient consultant staffing and on-call cover. There will be increased continuity of care by sub-specialist teams. Patients with acute medical illness should get better access to a specialist in that field which will improve outcomes and recovery times.

For those acutely ill people requiring general medicine inpatient services, they will also have access to the full range of emergency, critical care and diagnostic services at Stoke Mandeville.

Older people, BAME groups, those with learning disabilities and mental health illnesses and deprived communities are the equality groups most susceptible to requiring general medicine and inpatient care.

Given the high density of older people and BAME groups around Wycombe Hospital these two equality groups will potentially experience disproportionate negative impacts. This is particularly the case for older people because they are high users of all of the sub-services included in „general medicine inpatient care.‟ Whilst the investment in more community-based care and the multi-disciplinary assessment centre (see row below) would help to mitigate the need for emergency admissions for older people, this group is still likely to experience the impacts of these service changes to a disproportionate extent when an admission is required.







Elderly Care The proposed service will build on work which is already underway locally to support the delivery of increased care in community settings and the reduction of hospital admissions. For those older people requiring elderly care inpatient services, they will also have access to the full range of emergency, critical care and diagnostic services at Stoke Mandeville. This will support the many elderly patients who have complex co-morbidities.

Older people are the key equality group to be affected by changes proposed in this service area. There could be some disproportionate adverse effects for the small number of older people who require acute care and who need to travel further in future to reach this. This will affect not only the patient themselves but also elderly spouses, friends or other relatives who want to visit the patient. The impact of these longer travelling times will, however, in part be minimised by the „step down‟ ward at Wycombe meaning that as soon as patients no longer require treatment they can be moved closer to home and their local community.

There are also likely to be disproportionate positive impacts for older people because (a) a multidisciplinary assessment centre will be developed at Wycombe, which is expected to serve mainly older people whose symptoms mean that they are described as frail; and (b) they will have access to more community and home-based care.







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Breast Services Developing a Centre of Excellence for Breast Services will offer the best quality of care, clinical outcomes and patient experience. Staff will benefit from the sharing of expertise amongst a specialised, multi-disciplinary breast team. Breast service patients will be able to access all the relevant specialists in one place at their first assessment.

Women over 50 are the key equality group who will be affected by these proposals. As far higher numbers of women over 50 live around Wycombe as compared to Stoke Mandeville, there are likely to be disproportionate positive effects for this equality groups as a whole. However, those women living by Stoke Mandeville who require breast assessment services in future will have to access other hospital sites.




Vascular services

The proposals achieve critical mass, which enables improved clinical quality. Specialisation by doctors will improve outcomes. 24/7 interventional radiology rotas will be implemented.

Older people, BAME groups, those with learning disabilities and mental health illnesses and deprived communities are the equality groups most susceptible to requiring vascular services. Given the high densities of older people and BAME groups in Buckinghamshire, there could be disproportionate negative effects for these groups as a result of these services moving to the John Radcliffe. It should be noted, however, that whilst these groups could potentially be disproportionately disadvantaged the numbers affected in any one equality group are likely to be very small given the overall volume of patients at Wycombe hospital that require complex vascular services (105).



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10.2 Key findings – overall BHiB programme

The positive impacts that have been identified during this assessment are:

Health and clinical outcomes will be improved through the centralisation of acute services onto

fewer sites. This will enable surgeons, physicians and units to deliver care appropriately and safely,

maintain and improve their expertise and provide 24/7 on-call cover.

Investment in more community care and provision of care closer to home will reduce the time and

inconvenience of travelling and a hospital admission. This is likely to deliver particular benefits to older

people and other equality groups including those from deprived communities and BAME groups.

Patients will experience better quality of care, accessing services and competent decision-makers

more quickly and benefiting from continuity of services from a specialist team.

There are also some key benefits for staff which include the creation of more sustainable, specialist

teams; shared learning and development of expertise; and improved practice arrangements and rotas

which could benefit both recruitment and retention.

The assessment has also identified some potential negative impacts. These are:

The new service configuration could lead to confusion amongst patients about how to access the

healthcare that they need. This could lead to emergency cases presenting at a non-acute unit

resulting in the need to transfer them to a more appropriate site. This would delay treatment and could

affect clinical outcomes. Uncertainty about where to present could be a particular issue for some

equality groups who are accustomed to the current system. It should be noted, however, that a minor

injuries and illness service and the GP out of hours service will be available in Wycombe Hospital and in

emergency cases patients are less likely to self-present and rather would be transferred by ambulance,

minimising this risk.

The proposals may lead to fragmented pathways of care with more complicated discharge

arrangements. This will require new working relationships to ensure that patients are effectively

transferred back to a local setting for onward care. This could also lead to capacity challenges for

community and voluntary organisations which can play an important role in discharge.

Some patients will need to travel longer distances to access the care that they need in future. This

will particularly affect people living in the south of the county who will need to travel to Stoke Mandeville

(or in some cases Wexham Park) for acute inpatient services. Longer travelling times disproportionately

affect some equality groups, particularly older people, disabled people and those on low incomes who

find travelling long distances more of a challenge due to mobility, confidence or economic constraints. It

is worth noting though that these travel impacts will affect few numbers of patients per year for the

following reasons: (a) approximately 7,600 people who currently use Wycombe (3% of the annual

patient caseload) and 1,700 patients (0.3% of the patient caseload) who currently use Stoke Mandeville;

and (b) given the nature of the services moving to Stoke Mandeville (medical emergency services and

acute inpatient care) many of the will be transported by ambulance. Whilst patients may not be directly

affected due to ambulance transfer, the longer travelling distances will affect visitors,123

many of which

could also fall into the equality groups identified as vulnerable to these transport impacts.

_________________________ 123

NHS Buckinghamshire has commissioned a separate impact assessment to further consider the impacts on visitors.

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Short term capacity constraints at Stoke Mandeville hospital during transition whilst the services

undergo the proposed changes and capacity is increased at Stoke Mandeville hospital and in the

community. Successful implementation of the new system is reliant on effective functioning of and

transfer to step-down facilities at Wycombe, which again could take time to establish. Ambulance

services may also come under further strain as they are required to make longer transfers. The

involvement of the ambulance service in development of the proposals, however, should help to

mitigate this risk.

Finally, the proposed service configuration could affect patient choice.

10.3 Recommendations

The assessment has identified several improvements measures which will help to maximise the benefits

outlined above and mitigate the potential negative consequences. It is recommended that these measures

are considered by NHS Buckinghamshire as BHiB is taken forward:

It will be essential to get implementation of the new configuration right. Close joint working will be

necessary between hospital specialist, GPs and other primary care professionals if reductions in

inpatient admissions are to be delivered. The implementation plan also needs to set out enabling

milestones; address future commissioning; ensure change management is transparent; and establish

robust monitoring procedures.

A communication strategy will be critical. The reconfiguration‟s success will be dependent on clarity

and understanding about the services on offer at each site. Allied to this it will be important to clearly

explain the rationale and expected outcomes behind the changes. There are particular opportunities to

target affected equality groups (notably older people, BAME communities; those from deprived

communities and those who have learning disabilities and mental health illnesses) through

communication activities, to ensure that any particular challenges they could face are addressed.

Entering discussions with local representative groups to understand the most appropriate

communication channels would be a sensible first step in this strategy.

Equally as important will be excellent communication between the hospitals themselves. This will

help mitigate transitional problems associated with transfer protocols and fragmented pathways of care.

Good cross-site working will also be necessary to deal with patients with complex co-morbidities.

Discharge protocols underpinned by proactive management of patients through the inpatient pathway

and integrated hospital/community working will need to be established as a priority.

The BHiB transport subgroup is already developing mitigation steps to help alleviate concerns

about longer travel distances. Key measures that should be considered include the provision of travel

information for patients and their families, in a variety of formats and distributed though various different

media; pedestrian way-finding to help both patients and relatives navigate unfamiliar sites; and travel

planning for staff and patient access. Attention may also need to be given to those on lower incomes

who face long public transport trips to visit relatives who have lengthy inpatient stays.

In terms of meeting the aims and objectives of the Equality Duty:

This assessment concludes that the proposed changes will not lead to any unlawful discrimination.

All of the population will have access to the same level of services meaning opportunities are equal

at the point of service receipt. However, as some potential disproportionate negative impacts have

been identified for some protected groups (due mostly to the impact of short-medium term confusion

about changes to the services and increased travel times) the proposals won‟t necessarily advance

equality of opportunity for all at the point of demand. However the appropriate mitigation actions

already planned by BHiB and the additional actions suggested within this report, will largely address

this issue and help to ensure that equality of opportunity is maximised.

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In terms of fostering good relations, this aim has less relevance to the BHiB proposals. However, it is

possible that some slight benefits could be experienced through interaction with and experience of

new local communities when being treated at or visiting a different hospital. Any impacts are

expected to be marginal.

10.4 Concluding observations

The reconfiguration proposals have the potential to deliver significant positive impacts in terms of clinical

outcomes and health benefits. From the consultation document and the external review undertaken by

NCAT, it is clear that many of the impacts identified through this assessment have been considered and

are still being considered by BHiB and that much work has been undertaken involving a wide range of

stakeholders. In addition to these local considerations and solutions, measures suggested above in this

chapter could prove effective in minimising or mitigating any adverse effects. Implementing these

recommendations and particularly targeting the services, geographic areas and equality groups that have

been flagged as likely to be most affected by the changes will assist in enhancing the effectiveness of the

proposals but also augment the positive impacts that are likely to accrue.

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Appendix A. Distribution of populations with protected characteristics ____________________________________ 67 Appendix B. Option A for vascular services ________________________________________________________ 79

Appendices

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Appendix A. Distribution of populations with protected characteristics

This appendix provides additional information on the distribution of different populations with protected

characteristics across Buckinghamshire. Its focus is on those groups most likely to be affected by health

service reconfigurations in the county.

A.1. Young males

The map below illustrates the population density of younger males in Buckinghamshire.

Areas with the highest numbers of young males (here understood as people aged 16 to 29, and shown in

orange and red on the map below) are predominantly found in the southern parts of Buckinghamshire. The

towns of High Wycombe, Marlow, Beaconsfield, Amersham, and Chesham all have large numbers of

young males – with more than 150 persons per square kilometre being in this group.

Further north, the towns of Aylesbury and Buckingham also have high densities of young males. However,

the central and northern part of the county is predominantly rural and has very small numbers of males

aged 16-29. In these areas, shown in blue and green on the map, fewer than 25 persons per square

kilometre are in this age and gender bracket.

Buckinghamshire‟s main acute hospitals are in close proximity to large numbers of young males:

The highest numbers of young males served primarily by Stoke Mandeville Hospital are found in

Aylesbury and Wendover.

The highest numbers of young males primarily served by Wycombe hospital are found in High

Wycombe itself as well in the surrounding area and towns of Amersham, Marlow and others.

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Figure A.1: Young males aged 16-29 population density

Source: ONS mid year population estimates, 2010

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A.2. Older people

The map below illustrates the population density of older people in Buckinghamshire.

Areas with the highest numbers of older people (here understood as people aged 60 and over, and shown

in orange and red on the map below) are predominantly found in the southern parts of Buckinghamshire.

The towns of High Wycombe, Beaconsfield, Amersham, Chesham, Gerrards Cross, Marlow and Burnham

all have large numbers of older people – with more than 150 persons per square kilometre being over 60.

Further north, the towns of Aylesbury, Haddenham and Buckingham also have high densities of older

people. However, the central and northern part of the county is predominantly rural and has very small

numbers of older people aged over 60. In these areas, shown in blue and green on the map, fewer than 25

persons per square kilometre are over 60.

Buckinghamshire‟s main acute hospitals are in close proximity to large numbers of older people:

The highest numbers of older people served primarily by Stoke Mandeville Hospital are found in


The highest numbers of older people primarily served by Wycombe hospital are found in High Wycombe

itself as well in the surrounding area and towns of Beaconsfield, Marlow and others.

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Figure A.2: People aged 60 and over population density

Source: 2001 Census

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A.3. Females aged over 45

The map below illustrates the population density of females aged over 45 in Buckinghamshire.

Areas with the highest numbers of older women (here understood as women aged 45 and over124

, and

shown in orange and red on the map below) are also predominantly found in the more urbanised southern

parts of Buckinghamshire. The towns of High Wycombe, Beaconsfield, Amersham, Chesham, Gerrards

Cross, Marlow and Burnham all have large numbers of women aged over 45 – with more than 150 persons

per square kilometre falling into this group.

Further north, the towns of Aylesbury, Wendover, Princess Risborough, Haddenham and Buckingham also

have high densities of women aged over 45. However, the central and northern part of the county is

predominantly rural and has very small numbers of women aged over 45. In these areas, shown in blue

and green on the map, fewer than 25 persons per square kilometre are within this group.

Buckinghamshire‟s main acute hospitals are in close proximity to areas with high densities of women in this

age group:

The highest numbers of older women served primarily by Stoke Mandeville Hospital are found in


The highest numbers of women over 45 primarily served by Wycombe hospital are found in High

Wycombe itself as well in the wider surrounding area and the towns of Beaconsfield, Marlow and others.

_________________________ 124

This age range was chosen to cover the full age range covered by the NHS breast screening programme.

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Figure A.3: Women over 45 population density

Source: ONS mid year population estimates 2010

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A.4. Disabled people

The map below illustrates the population density of disabled people in Buckinghamshire.

Areas with the highest numbers of disabled people (here understood as people claiming Disability Living

Allowance – DLA and shown in orange and red on the map below) are predominantly found in

Buckinghamshire‟s large towns. The highest numbers are found in the towns of High Wycombe,

Amersham, Chesham, and Marlow, all of which have large numbers of disabled people – with more than 30

persons per square kilometre claiming DLA.

Further north, the town of Aylesbury has the highest densities of disabled people, while Princess

Risborough, Steeple Claydon and Buckingham also have high densities of disabled people, with more than

10 persons per square kilometre claiming DLA.

The central and northern part of the county is predominantly rural and has very small numbers of disabled

people. In these areas, shown in blue and green on the map, fewer than one person per square kilometre

is disabled.

Buckinghamshire‟s main acute hospitals are in close proximity to the largest numbers of disabled people:

The highest numbers of disabled people served primarily by Stoke Mandeville Hospital are found in

Aylesbury, where much of the town has high densities of DLA claimants.

The highest numbers of disabled people primarily served by Wycombe hospital are found in High

Wycombe itself as well in the surrounding area and towns of Beaconsfield and Marlow, which also have

high densities of DLA claimants.

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Figure A.4: DLA claimants population density


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A.5. BAME groups

The map below illustrates the population density of people from BAME groups in Buckinghamshire.

Areas with the highest numbers of people from BAME groups (here understood as people from non white

British backgrounds and shown in orange and red on the map below) are again predominantly found in the

south of the county, and in and around Buckinghamshire‟s larger towns. The highest numbers are found in

the towns of High Wycombe, Beaconsfield, Amersham, Chesham, Gerrards Cross, Marlow and Burnham.

All of these towns, and much of the area in between them have large numbers of people from BAME

backgrounds – with more than 20 persons per square kilometre from these groups.

Further north, the town of Aylesbury (as well as its neighbours Stoke Mandeville and Wendover) has the

highest densities of people from BAME backgrounds, while Princess Risborough, Haddenham,

Buckingham and Winslow also have high densities of people from BAME groups.

The predominantly rural central and northern part of the county again has very small numbers of people

from non white British backgrounds. In these areas, shown in blue and green on the map, fewer than five

people per square kilometre are from BAME backgrounds.

Buckinghamshire‟s main acute hospitals are in close proximity to the most significant BAME populations:

The highest numbers of non white British people served primarily by Stoke Mandeville Hospital are

found in the urban Aylesbury-Wendover corridor, where much of these towns has high densities of

BAME people.

The highest numbers of BAME people primarily served by Wycombe hospital are found in High

Wycombe itself as well in much of the surrounding area and towns from Amersham, Beaconsfield and

further south down to northern parts of Windsor and Slough, which also have high densities of people

from BAME backgrounds.

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Figure A.5: People from BAME groups population density


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A.6. Deprived communities

The map below illustrates the levels of deprivation in Buckinghamshire. Deprivation is not prevalent in the

county. None of the county‟s lower super output areas (LSOAs) fall within the „most deprived‟ Index of

Multiple Deprivation (IMD) quintile125

for 2010. The county does, however, have some pockets of

deprivation. These are focussed in three main areas:

Aylesbury

High Wycombe

Amersham

Aylesbury and High Wycombe in particular have a number of LSOAs in the second most deprived quintile.

The remainder of the county, however, falls within the less deprived IMD quintiles, with the vast majority

being in the fourth most deprived and the least deprived

Buckinghamshire‟s main acute hospitals are in close proximity to these key deprived areas:

The most deprived communities served primarily by Stoke Mandeville Hospital are found in Aylesbury.

The most deprived communities served by Wycombe hospital are found in High Wycombe itself.

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125 The Index of Multiple Deprivation is a national exercise undertaken by the Department for Communities and Local Government. Based on a number of factors, ranging from income to employment to access to services, the Index ranks every lower super output area in England (of which there are 32,482) from the most to the least deprived. This ranking is then divided into five 20% ranges - quintiles – again from the most to the least deprived.

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Figure A.6: Deprivation by IMD quintile

Source: Department for Communities and Local Government 2010

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B.1. Option A

The John Radcliffe Hospital in Oxfordshire would provide all emergency and elective complex inpatient

vascular surgery, including operations to prevent strokes caused by carotid artery disease (carotid

endarterectomy or CEA) to Buckinghamshire, Berkshire and Oxfordshire residents.

Wycombe Hospital would retain vascular surgeons to undertake day case surgery, diagnostics and local

outpatient provision. Surgeons would travel to the John Radcliffe as part of an emergency rota to cover the

Berkshire, Buckinghamshire and Oxfordshire area and to carry out elective complex inpatient surgery on

their local patients with the full support of an expert vascular team.

This would increase the volume of patients being treated at the vascular unit at the John Radcliffe, thereby

increasing the level of expertise at the unit. Consultant level doctors would be available 24/7.

This means that patients requiring relatively straight forward treatment which is not urgent would continue

to be seen at Wycombe Hospital.

Appendix B. Option A for vascular services

Documents

Health and Equality Impact AssessmentHealth and Equality Impact Assessment Confidential Mott MacDonald, Spring Bank House, 33 Stamford Street, Altrincham, Cheshire WA14 1ES, United