Equality, Good Relations and Human Rights SCREENING TEMPLATE

Equality, Good Relations and Human Rights SCREENING TEMPLATE Note: 1) Proposals cannot be implemented until an Equality Screening or EQIA has been completed 2) This template should be completed in conjunction with the accompanying Guidance Notes 3) Completed Screening Templates are public documents and will be posted on the Trust s website Section 1: INFORMATION ABOUT THE POLICY/PROPOSAL (1.1) Name of the policy/proposal Centralisation of Warfarin Service in BHSCT (1.2) Status of policy/proposal (please underline) New Existing Revised (1.3) Department/Service Group: (please underline) (1.4) Description of the policy including intended aims/outcomes Corporate Services Group (Please specify) Nursing and User Experience Unscheduled and Acute Care Surgery & Specialist Services Specialist Hospitals & Women s Health Children s Community Services Warfarin services in the Belfast Health and Social Care Trust (BHSCT) were delivered on three sites; Adult Social & Primary Care - Belfast City Hospital (BCH) - Royal Victoria Hospital (RVH) - Mater Hospital (MIH) In 2012 a review of Warfarin Services in the Belfast Health and Social Care Trust commenced as a result of both the National Patient Safety Agency Alert no. 18 as

well as the Transforming your Care document. Historically patients referred to the warfarin clinics at all 3 Belfast Health and Social care sites for warfarin management remained under the care of the clinic for an indefinite period of time. This meant that the service expanded to the extent that there were delays in new patient referrals being dealt with. In addition, patients who through attendance at the clinic achieved a stable INR (the blood test used to monitor coagulation levels) remained under the care of the hospital clinic, many travelling long distances at regular intervals. In 2012, a multi professional team, involving nurses and doctors, identified that for patients with a stable INR, warfarin management could be carried out by their General Practice. It was recognised that while this would mean discharge from the hospital team, the same level of care and INR monitoring could be achieved by accessing treatment from a GP, which in many cases would be located closer to the home of the service user, therefore increasing the accessibility of the service for many. To date over 300 patients have been discharged from the BCH and RVH clinic back to their GP. In August 2013 the RVH clinic transferred into the BCH clinic and the current BCH clinic expanded as a result. An equality screening template was completed in 2013 for those service users who would continue to receive Warfarin management

from Belfast Health & Social Care Trust; specifically patients whose treatment would be managed from BCH as opposed to RVH. There was no staff impact at the time as the one member of staff who provided services to the Warfarin Clinic in the RVH would work across both sites as agreed on commencement to the post. Centralising both clinics has allowed for the standard of care provided to patients to be standardised and maintained in line with the gold standard recommendation. Proposal This proposal aims to; Identify those patients in the Mater hospital who are currently assessed as stable on Warfarin i.e. INR readings within the therapeutic range. Engage with primary care on a practice-by-practice basis in order to ensure we continue to deliver high-quality evidence based service which remains focused on the needs of the patient and endeavour to put in place a seamless handover back to GP (primary) care. Advise the clinical situations for patients who will be referred to and managed at a secondary care level. Patients are deemed stable for transfer to a primary care provider when they have

had three consecutive INR readings within the therapeutic range with a minimum of four weeks between each reading and whenever the primary care provider has access to a community based warfarin monitoring/ dosing system. At the beginning of this project, there were 125 patients receiving warfarin management in the Mater hospital with no new patient referrals from 2012. Following the discharge of patients with a stable INR, there are now only 19 patients requiring management of their warfarin in the clinic; 9 of these patients have been identified as suitable for discharge to their GP. It is then proposed to transfer the Mater clinic onto the BCH site to allow for the standard of care provided to patients to be standardised and maintained. The BCH warfarin clinic will continue to handle referrals, via Dr GM Benson, in the following situations: Slow induction of warfarin therapy as indicated by primary/ secondary colleagues. Once the patient fulfils the definition of stable, they will be referred back to primary care for onward monitoring. Provide monitoring/ dosing warfarin service for those primary care practises who do not offer such a service. As a consultative role in helping those patients who are encountering instability e.g. patients with liver disease and/ or alcoholism.

We are aware that this process will involve a number of nursing staff, and we estimate that this will take a number of months to complete. All patients have been advised of the planned change in service. For those patients that attend the Mater Hospital who are currently assessed as stable on Warfarin i.e. INR readings within the therapeutic range the Trust will engage with primary care on a practice-by-practice basis in order to ensure we continue to deliver highquality evidence based service which remains focused on the needs of the patient and endeavour to put in place a seamless handover back to GP (primary) care. Those 9 patients that currently attend the Mater Hospital and will continue to require management of their condition in a hospital setting will now be required to attend the BCH Anticoagulant clinic. They will be informed of the proposed change face- to- faced and will also receive a letter to provide them with the opportunity to tell the Trust if they believe that proposal may have an adverse impact on them in terms of Section 75. Current workforce and implications of the proposal

(1.5) How will the policy/proposal be implemented? (1.6) Who are the internal and external stakeholders (actual or potential) that the policy/proposal could impact upon? (E.g. service users/staff/ other public sector organisations/trade unions/ professional bodies/independent, voluntary or community sector) We have 8 staff Nurses trained to work in these clinics; these staff will be assigned other clinics, as normal practice when clinics are cancelled and so forth. Management have discussed this proposal with the Trade Unions. In line with the organisations management of Change Framework staff were consulted by the Ward Sister and Assistant Service Manager for the area. In line with this process staff was offered the opportunity to discuss in one to one meetings any adverse impact on equality grounds. At the beginning of this project, there were 125 patients receiving warfarin management in the Mater hospital with no new patient referrals from 2012. Following the discharge of patients with a stable INR, there are now only 19 patients requiring management of their warfarin in the clinic; 9 of these patients have been identified as suitable for discharge to their GP. It is then proposed to transfer the Mater clinic onto the BCH site to allow for the standard of care provided to patients to be standardised and maintained. The stakeholders are the staff involved in each Warfarin clinic within the Belfast Trust and the service users who attend each clinic. Section 2: CLASSIFICATION OF POLICY The purpose of this Section is to identify those policies/proposals which have no impact on equality e.g. policies of a purely clinical or technical nature. It should be noted however that the majority of policies /proposals will have some equality impact on staff and/or service users and will require the completion of the entire template.

PART A: (2A.1) Is there an impact on equality of opportunity for those affected by this policy, for each of the S75* equality categories? (2A.2) Are there better opportunities to promote equality of opportunity for people within the S75 categories? (2A.3) Does the policy impact upon good relations between people of a different religious belief, political opinion or racial group? (2A.4) Are there opportunities to better promote good relations between people of a different religious belief, political opinion or racial group? (2A.5) Are there opportunities to encourage disabled people to participate in public life and promote positive attitudes toward disabled people? (2A.6) Does the policy/proposal impact on Human Rights? (2A.7) If you have answered Yes to any of the above questions proceed to Section 2B overleaf. Yes No If you have answered No to all of the above questions the policy may be screened out at this stage. Please give reasons supporting this decision below then sign and date below then forward to the Health & Social Inequalities Team for consideration Lesley.Jamieson@belfasttrust.hscni.net Approved Lead Officer: Position: Date: Countersigned by: Health Inequalities Manager: Employment Equality Manager: *S75 Equality Categories: Age * Dependants * Disability * Gender * Marital - Civil Partnership Status * Political Opinion * Race * Religion * Sexual Orientation

PART B (2B.1) Are there any factors that could contribute to/detract from the intended aim/outcome of the policy/ proposal? Financial, legislative or other constraints?. There are no financial factors. (2B.2) Other policies/strategies/information with a bearing on this policy/proposal (for example internal or regional policies) - What are they and who owns them? In 2012, the Department of Health, Social Services and Public Safety in Northern Ireland published a new health strategy Transforming Your Care which aims to support patients to be cared for close to home, with particular emphasis on putting in place services which prevent patients having to travel to hospitals unnecessarily. The Belfast Health and Social Care Trust is working closely with primary and community services to implement this strategy. Historically patients referred to the Warfarin clinic at the Belfast City Hospital for warfarin management remained under the care of the clinic for an indefinite period of time. This meant that the service expanded to the extent that there were delays in new patient referrals being dealt with. In addition, patients who through attendance at the clinic achieved a stable INR (the blood test used to monitor coagulation levels) remained under the care of the hospital clinic, many travelling long distances at regular intervals. In 2012, a multi-professional team, involving nursing and doctors, identified that for patients with a stable INR, warfarin management could be carried out by their General Practice. It was recognised that while this would mean discharge from the hospital team, the same level of care and INR monitoring could be achieved. This will allow those patients whose INR level leaves them unsuitable for GP

monitoring to continue to be appropriately cared for within the Belfast City Hospital clinic. (2B.3) Provide details of how you have or how you intend to involve stakeholders (refer 1.6 above) when screening this policy/proposal A letter and questionnaire was posted to the remaining 19 patients who are currently attending the Mater Hospital Warfarin Clinic; 9 of these have been identified as being suitable for discharge to their GP. Of the 19 questionnaires that were distributed, a total of 10 patients returned their completed questionnaires; the responses from these have been collated. The majority of concerns expressed by patients included: Transport and the cost of transport to and from the BCH site Reduced mobility Distance to and from the car park in the BCH site The service aims to overcome the issues raised by patients by holding an Open Day at the Anticoagulant Clinic in Belfast City Hospital on Thursday 18 th August 2016 for all new and current patients to attend. Patients will be invited to the Open Day by letter which will include transport information. On the day, patients will also be provided with an information pack including details of further transport available to them. The individual needs of each patient will be considered. Staff have been consulted at regular team meetings that have been arranged to discuss the Warfarin Service.

Section 3: AVAILABLE EVIDENCE, CONSIDERATION OF IMPACTS AND MITIGATION You will need to collect quantitative and qualitative equality data for those service users and staff affected using the templates provided in Tables 1 & 2 at the end of this document. Taking into account this data and the information gathered in Sections 1&2 you should now identify, for each of the nine Section 75 categories, the level of impact, mitigation measures and opportunities to better promote equality of opportunity. NB: Where both staff and service users are impacted, a separate table for each is required. 3A) SERVICE USERS Equality Category Level of Impact Mitigation Measures and consideration of alternative policies or actions that might lessen the severity of the equality impact (where Major or Minor Impact Major Minor None identified) Age The majority of those impacted are older people aged 65+ it is therefore likely that they will have a disability or restricted mobility. All patients affected will be consulted and offered the opportunity to identify if they believed the proposal would have an adverse impact and if so, this will be mitigated. Patients will be provided with information on transport and the individual needs of each patient will be considered and mitigated where possible. Dependant Status Disability As above Gender Marital Status Race (Ethnicity) Religion

Political Opinion Sexual Orientation Multiple Identity e.g. disabled minority ethnic people or young Protestant men. 3B) STAFF As above Equality Category Level of Impact Mitigation Measures and consideration of alternative policies or actions that might lessen the severity of the equality impact (where Major or Minor Impact Major Minor None identified) Age In line with the organisations management of Change Framework staff were consulted. In line with this process staff were offered the opportunity to discuss in one to one meetings any adverse impact on equality grounds. The small number of staff involved, make it difficult to carry out any meaningful equality analysis. The advice from the Equality Commission is that figures should not be provided for small groups of staff as it could lead to the identification of individuals. Dependant Status Taking above into consideration as a general overview please note there may be potential impact on gender, community background and BME status. Disability

Gender Marital Status Race Ethnicity Nationality Religion Community Background Political Opinion Sexual Orientation Religious Belief Multiple Identity e.g. female staff with caring responsibilities Section 4: GOOD RELATIONS To what extent is the policy/proposal likely to impact on good relations between people of different religious belief, political opinion or racial group? Good relations category Level of impact Mitigation Measures and consideration of alternative policies or actions that might lessen the severity of the equality impact (where Major or Minor Impact Major Minor None identified) Religious belief

Political opinion Racial group Section 5: DISABILITY DUTIES How does the policy/proposal or decision currently encourage disabled people to participate in public life and promote positive attitudes towards disabled people? Consider what other measures you could take. For example, have staff received disability equality training or training on the Trust s Patient and Client Experience Standards? The change in service is aimed at ensuring that patients impacted can access the same service via their local GP, therefore, avoiding having to travel to the Mater Hospital. The Trust is committed to ensuring equality of opportunity for all service users and staff in terms of disability and complies with the Disability Discrimination Act 1995, the United Nations Convention on the Rights of people with disabilities. The Human Rights Act 1998 and Section 75 of the Northern Ireland act 1998. The Trust has a number of policies/strategies in place including the Disability Action Plan, aimed at encouraging disabled people to participate in public life and promote positive attitudes towards disabled people. All staff has access to Disability awareness training.

Section 6: HUMAN RIGHTS Does the policy/proposal affect human rights in a positive or negative way? NB: If you identify potential negative impact in relation to any of the Articles seek advice from your line manager and/or a representative from the Equality Team. It may also be necessary to seek legal advice. Article Positive impact Negative impact * A2: Right to life A3: Right to freedom from torture, inhuman or degrading treatment or punishment A4: Right to freedom from slavery, servitude & forced or compulsory labour A5: Right to liberty & security of person A6: Right to a fair & public trial within a reasonable time A7: Right to freedom from retrospective criminal law & no punishment without law A8: Right to respect for private & family life, home and correspondence. A9: Right to freedom of thought, conscience & religion A10: Right to freedom of expression A11: Right to freedom of assembly & association A12: Right to marry & found a family A14: Prohibition of discrimination in the enjoyment of the convention rights 1st protocol Article 1 Right to a peaceful enjoyment of possessions & protection of property 1 st protocol Article 2 Right of access to education Please outline any actions you will take to promote awareness of human rights and evidence that human rights have been taken into consideration in decision making processes. Neutral impact Mandatory, equality, good relations and human rights training is provided to all staff. Belfast Trust delivers human rights training and training in regard to the United Nations Convention on Rights of Persons with Disabilities and the UN Convention on the Rights of Children. The Trust has committed to work in partnership to develop a human rights based approach to health and social care.

* A negative impact is where human rights have been interfered with or restricted Section 7: SCREENING DECISION Major Minor None (7.1) How would you categorise the impacts of this policy/proposal? (7.2) If you have identified any impact, what mitigation have you considered to address this? (7.2) Do you consider the policy/proposal needs to be subjected to on-going screening? (7.3) Do you think the policy/proposal should be subject to an Equality Impact Assessment (EQIA)? NB: A full Equality Impact Assessment (EQIA) is usually confined to those policies or proposals considered to have major implications for equality of opportunity. (7.4) Monitoring- Please detail how you will monitor the effect of the policy/proposal for equality of opportunity and good relations, disability duties and human rights? For those patients that will now be managed by their GP, this will most probably be more suitable for patients as it does not require them to travel to hospital. Those patients that will be transferred from the Mater Hospital to the BCH will be provided with the opportunity to express if the proposal will have an adverse impact in terms of Section 75, if an adverse impact regarding Section 75 is identified, all possible mitigation will be implemented. Yes Yes No No Reasons The proposal is aimed at improving access to services as the majority of patients can now be managed by their local GP. For those patients that will be transferred to the BCH any identified adverse impact will be mitigated. Reasons As above. The BCH Warfarin clinic will complete a post-transfer questionnaire and evaluation. The policy will be monitored as part of the ongoing screening and should the impact be more than adverse than initially anticipated, the Trust will revisit the proposal and introduce additional mitigating measures. Please sign and date below and forward to the Health & Social Inequalities Team Lesley.Jamieson@belfasttrust.hscni.net

Approved Lead Officer Position Date 28/6/16 Countersigned by: Health Inequalities Manager Employment Equality Manager Veronica McEneaney Martin McGrath Tables 1 and 2: Qualitative and Quantitative Data required to assess level of impact, mitigation and opportunities to better promote equality of opportunity (As referred to in Section 3) Table 1: SERVICE USERS *2011 Census Data unless otherwise stated Equality Category Service users Quantitative Data* Qualitative Data Belfast / Castlereagh population Service users affected (Needs, Experiences, Priorities) 1. Age 0-16 16-24 25-34 35-44 45-54 55-64 65+ 22% 11% 12% 14% 14% 12% 15% Due to the small number of patients affected by the proposal, their Section 75 information cannot be used. The advice from the Equality Commission is that figures should not be provided for small groups of patients as it could lead to the identification of individuals. Due to the nature of the service a high number of patients will be 65+. The proposal is aimed at ensuring that those patients with a stable INR can have their warfarin management carried out by their General Practice receiving the same level of care and INR monitoring, which in many cases would be located closer to the home of the service user, therefore increasing the accessibility of the service for many. A total of 10 patients will transfer from attending the Mater Hospital Clinic to attending Belfast City Hospital Clinic. The distance between the Mater Hospital and

BCH is 2.1 miles. These patients have received questionnaires to provide them with the opportunity to highlight any possible adverse impact. Any adverse impact identified will be addressed where possible. 2. Dependent Status Caring for a child dependant older person/ person with a disability None Not known 12% of usually resident population provide unpaid care Due to the age of the majority of patients, it is unlikely that they will have dependants. It may be probable, however, that due to age and other associated illnesses, some patients may be dependent on a carer. There is no information to evidence an adverse impact due to dependent status. 3. Disability Yes No Not known 21% 69% n/a More than one-fifth (21%) of adults in Northern Ireland have at least one disability. Amongst children, 6% are affected by a disability. One in every three people aged 45-49 (33 per cent) and two in every three people aged 70-74 (67 per cent) having at least one longterm condition. Among those aged 85 and over, nine out of every ten people (90 per cent) had at least one long-term condition (Table DC3101NI, NISRA). There is a clear increase in Census information indicates that two in every three people that are age between 70 74 have at least one long term condition that may be classed as a disability. It is therefore likely that the majority of patients affected by this proposal will have a disability. For those patients that can be treated by their local GP, the proposal will have a beneficial impact as they will not have to travel to a hospital clinic. A total of 10 patients will transfer from attending the Mater Hospital Clinic to attending Belfast City Hospital Clinic. The distance between the Mater Hospital and

disability with age, rising to 60% amongst those aged 75 and above. Indeed, amongst the very elderly, aged 85 and above, twothirds are living with a disability or disabilities. Females, generally, have a higher prevalence of disability than males. Almost one-quarter (23%) of adult females living in Northern Ireland households indicated that they had some degree of disability, compared with around one-fifth (19%) of adult males. However, amongst the very youngest within Northern Ireland s households, the prevalence of disability is higher amongst boys than amongst girls. Around 8% of boys aged 15 and under were found to have a disability, compared with 4% of girls of the same age. The most common types of disabilities reported by adults were associated with chronic illnesses, pain, mobility difficulties and dexterity difficulties. Amongst children, the most common types of disabilities were linked with BCH is 2.1 miles. These patients have received questionnaires to provide them with the opportunity to highlight any possible adverse impact. Any adverse impact identified will be addressed where possible. If patients require support with communication in relation to this proposal, this will be provided.

chronic illnesses, learning difficulties and social / behavioural difficulties. 4. Gender Female Male 51% 49% Male 70 Female -47 The majority of patients affected by this proposal are male, there is no indication however, that there would be an adverse impact with regard to gender. 5. Marital Status Married/Civil P ship Single Other/Not known 47% 36% 17% Using census statistics as a proxy indicator, the majority of those affected would be married. There is no evidence that here would be an adverse impact regarding marital status. 6. Race Ethnicity White Black/Minority Ethnic Not known 98% 2% n/a Using census statistics as a proxy indictor, the majority of those affected would be white. There is no information to suggest that there would be an adverse impact in terms of ethnicity. If support is required in terms of communication regarding this proposal, interpreting or translation will be provided. The Belfast Trust is committed to the promotion of good relations in the areas of

race, religion and political opinion. The Trust has a good relations strategy aimed at ensuring that all staff and service users have equality of access to services and all Trust buildings are safe and welcoming for everyone. All staff attends mandatory equality, good relations and human rights training. 7. Religion Roman Catholic 41% Using census information as a proxy indicator there would be a slightly higher proportion of service users from the Protestant religion that may be impacted by the proposal. There is no information however, to indicate that the impact would be adverse in terms of religion. The Belfast trust is committed to the promotion of good relations in the areas of race, religion and political opinion. The Trust has a good relations strategy aimed at ensuring that all staff and service users have equality of access to services and all Trust buildings are safe and welcoming for everyone. All staff attends mandatory equality, good relations and human rights training.

Presbyterian Church of Ireland Methodist Other Christian 42% Buddhist Hindu Jewish Muslim Sikh Other None 17% 8. Political Opinion * 2011 Assembly election Broadly Nationalist Broadly Unionist Other Do not wish to answer/ Unknown 45% 48% 2% 5% As above 9. Sexual Orientation *2012 report by Disability Action & Rainbow Project Opposite sex Same sex Same and Opposite sex Do not wish to answer /Not known Estimated 6-10% of persons identify as lesbian, gay, bisexual This information is not available. It is estimated that between 6 10% of the population are lesbian, gay or bisexual. There is no evidence to indicate that the relocation would have an adverse impact with regard to sexual orientation.

The small number of staff involved, make it difficult to carry out any meaningful equality analysis. The advice from the Equality Commission is that figures should not be provided for small groups of staff as it could lead to the identification of individuals. Please Refer to Section 3B Staff Table 2: STAFF *@January 2015 Equality Category 1. Age <25 25-34 35-44 45-54 55-64 65+ Groups Quantitative Data Qualitative Data Trust Staff affected workforce* 4% 24% 26% 29% 15% 2% 2. Dependant Status 3. Disability 4. Dependants No Dependants Not known Yes No Not known 22% 21% 57% 2% 68% 30% Gender Female 78%

Male 22% 5. Marital Status 6. Race a) Ethnicity Married/ Civil P ship Single Other/Not known BME White Not Known 55% 33% 12% 4% 80% 16% b) Nationality 7. Religion GB Irish Northern Irish Other Not known 15% 8% 2% 1% 74% a) Community Background Protestant Roman Catholic Neither 44% 50% 6%

b) Religious Belief Christian Other No religious belief Not known 26% 1% 7% 66% 8. Political Opinion * 2011 Assembly election 9. Sexual Orientation Broadly Nationalist Broadly Unionist Other Do not wish to answer/ Unknown Opposite sex Same sex or both sexes Do not wish to answer /Not known 6% 7% 8% 79% 39% 1% 60%