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Initial Equalities Analysis Desk research Verve Communications August 2018

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Page 1: Initial Equalities Analysis Desk research...NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG's estimated population density in mid-2016 is 4831.51

Initial Equalities Analysis

Desk research

Verve Communications August 2018

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Contents

A. North London Partners in Health and Care.................................................................... 3

B. Equalities analysis overview ........................................................................................... 6

C. Overview of scoping report............................................................................................ 8

C.1. North central London population profile ............................................................................ 9

D. Insight into protected characteristic groups ................................................................ 10

D.1. Age (older people) ............................................................................................................ 11

D.2. Disability check stats below .............................................................................................. 13

D.3. Sex: Female ....................................................................................................................... 16

D.4. Gender Reassignment ...................................................................................................... 18

D.5. Race and ethnicity: White populations ............................................................................ 19

D.6. Race & Ethnicity: Black populations ................................................................................. 21

D.7. Socio-economic status ...................................................................................................... 23

D.8. Carers ................................................................................................................................ 25

E. Summary of Groups Within Scope ............................................................................... 26

F. Summary of the geographical distribution of ‘scoped in’ groups ................................ 27

G. Concluding observations .............................................................................................. 30

H. Next steps .................................................................................................................... 32

I. APPENDICES – Larger versions of maps ....................................................................... 33

33

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A. North London Partners in Health and Care

North London Partners in Health and Care (NLP) is a partnership of health and care organisations from the five London boroughs of Barnet, Camden, Enfield, Haringey and Islington.

NLP have launched a review of adult elective orthopaedic services across North central London (NCL) following agreement at the NCL Joint Commissioning Committee meeting on 1 February 2018. This review will be clinically led and initiated as part of the North central London Sustainability and Transformation Partnership (NCL STP).

The decision to embark on a review has stemmed from recognising that whilst there are many examples of good practice within their current service offer, the care is fragmented with adult elective orthopaedic services available on ten different sites within NCL. The review will consider potential options for change to both improve quality of care and achieve better outcomes and value for patients. The ambition of NLP STP is to create comprehensive adult elective orthopaedic services for NCL which would be seen as centres for excellence with an international reputation for high-quality patient outcomes and experience, education and research.

1 North London Partners Draft Case for Change Adult-elective-orthopaedic-review/

The first phase of this process will: Establish the Adult Orthopaedic Services Review Group – with

representatives from trusts, CCGs and patients Define the vision and case for change based on clear, detailed

evidence including issues/gaps Develop, evaluate and shortlist options for improving services Develop a pre-consultation business case (if options for change

are recommended)

Our initial equality analysis scoping report (desk research) forms a necessary part of defining the vision and draft case for change based on clear, detailed evidence including issues and gaps.

The draft case for change document1 summarises the evidence which supports the adult elective orthopaedic services review. This started in February 2018 and will continue to March 2019 to assess whether there are steps which could be taken to:

Improve outcomes and experience for patients Improve quality and efficiency of services by reducing

unwarranted variation

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Make efficiencies as a natural consequence of these improvements; improving value for money.

The review will consider these opportunities and thoroughly assess the options for change; options which would help define the future scope and model for the service and is split into several distinct phases:

1. Set up and planning for the review (February-July 2018) 2. Public and stakeholder engagement (summer and early autumn

2018) 3. Reflection on inputs from the engagement phase and finalising

proposed service model (October - November 2018) 4. Development of a pre-consultation business case (November-

March 2019) 5. Subsequent phases for consultation and decision-making;

implementation to be informed by the service model decided on (dates to be determined).

This draft timeline is flexible, as NLP want to ensure that they are engaging properly with stakeholders and residents. NLP have committed to extending the timeline to achieve this if necessary.

We understand that the views and ideas expressed in the draft case for change do not, at this stage, represent the view of the commissioners as to the best way forward. The development and refinement of the service model is an iterative process; commissioners will make a decision in respect of the final service model following phase three, and if required, a formal consultation process.

Engagement The fact that this scoping report has been launched and embedded so early in the process is a positive statement of commitment – often such assessments are conducted late and their potential helpful impact for patients and residents is reduced. A critical success factor for the review process is around ensuring appropriate engagement with patients, the public, clinicians and other staff. This scoping report will feed into the further development of an existing engagement plan that involves listening to patients to establish what they consider important about the services, and what could be improved into the future, before developing options about what might change. A key commitment of the NCL STP is to involve patients who share one or more protected characteristic so that future plans are inclusive, eliminate discrimination, advance equality and foster good relations between those who share one or more protected characteristic and those who do not. The local approach to patient and public involvement is being developed in discussion with the five local Healthwatch organisations and the Joint Health Overview and Scrutiny Committee, this report should inform these discussions. Good equality analyses are based on good insight and good engagement. Throughout the engagement process, the capacity of current Joint Strategic Needs Assessments (JSNAs) and approaches to engagement should be kept under critical review. Current services

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Secondary care orthopaedic interventions for NHS patients are currently delivered from NCL on ten separate NHS and independent sector sites within NCL (plus other NHS and independent sector sites outside of NCL). The sites are listed below and identified on the map below (figure 1) – the map at figure 2 also shows elective commissioner activity by Healthcare Resource Groups (HRG) (2014-15) across the five boroughs:

Figure 1

Royal National Orthopaedic Hospital UCLH - University College Hospital UCLH - National Hospital for Neurology and Neurosciences,

Queens Square Whittington Hospital North Middlesex University Hospital Royal Free London – Royal Free Hospital Royal Free London - Chase Farm Hospital Highgate Private Hospital (Aspen) The Cavell Hospital (BMI Healthcare) The Kings Oak Hospital (BMI Healthcare)

Figure 2 Elective commissioner activity by Healthcare Resource Groups (HRG)

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The elective HRG activity for NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG is: 245,972 admissions (68.1% of all admissions), 430,850 bed days (42.1% of all bed days), 1.8 days average length of sta

B. Equalities analysis overview

Equalities analysis To support the review process and to ensure that North London Partners in health and care has considered the potential impacts on those characteristics protected under the Equality Act 20102, including those who identify as carers, Verve Communications was commissioned to undertake an independent initial equalities analysis through analysis of the draft case for change for elective orthopaedic services. 3 Through initial desk research, we have looked at existing data from other programmes looking at elective orthopaedic services in other parts of the country, Strategic Health Asset Planning and Evaluation (SHAPE), plus local Joint Strategic Needs Assessments, London Observatory, local insight work, London Data, EDS2 documents across

2 The protected characteristics are; age, disability, pregnancy and maternity, race and ethnicity, sexual orientation, gender reassignment, religion and belief, marriage and civil partnership and gender.

each CCG (where available), earlier EIAs from Our Healthier South East London which draws on relevant national research from NHS England and the British Orthopaedic Association Scope and objectives The objectives of this initial equalities analysis are to: Identify positive and any negative impacts for the population to

inform the discussion towards service reconfiguration Identify which (if any) of the protected characteristics groups are

more likely to be affected by the proposals due to their propensity to require different types of health services.

Set out how the core constituent public sector health organisations can fulfilling the Public Sector Equality Duty (PSED)

3 North London Partners Draft Case for Change Adult-elective-orthopaedic-review/

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through working to: eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited under the Equality Act 2010, advance equality of opportunity between people who share a protected characteristic and those who do not and foster good relations between people who share a relevant protected characteristic and those who do not share it.

Provide recommendations on ways in which positive impacts can be maximised and ways in which to mitigate or minimise any adverse effects.

The process of our equalities analysis is designed to be an interactive ‘work-in-progress’ which will be revisited or re-examined during the development of any potential consultation process that may be required in the future and throughout the engagement process. Our draft scoping report follows, if required the analysis could be extended to include insight and advice through potential consultation and post consultation phase.

We are aware that the health and wellbeing of populations at large are enhanced when patients, service users, carers, clinicians, practitioners and staff of services - are actively engaged within a joint effort to meet health needs and to reduce health inequalities through proportionate, equitable and continuing means.

The approach that we have used to conduct this assessment has set out to seek evidence of any evolving actions our partners are taking to meet their respective Public Sector Equality Duties in pursuit of local commissioning strategies and equality objectives

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C. Overview of scoping report

The objectives of this scoping report are to:

Look at demand for elective orthopaedics services by each protected characteristic group and identify groups for engagement throughout the review process.

Identify existing health inequalities, access barriers and equality issues to be considered.

Identify groups who share one or more protected characteristics and might have a higher need for orthopaedic services and may be impacted more by a change in the delivery of service.

Provide recommendations about key groups that may be targeted if there is a need for consultation.

Provide advice on equalities questions for inclusion for any potential public consultation.

Evidence for this scoping report has been gathered through:

Demographic analysis which sets out the characteristics of the North central London population, and particularly the distribution of residents from different equality groups.

An evidence review of available literature which identifies population groups who may have a disproportionate need for services.

Feedback gathered via previous and related strategic and community engagement (particularly through the work on MSK services)

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C.1. North central London population profile

The total population and the density of the population provide a baseline from which to break down the key socio-demographic trends in our study area. Total Population The table below shows the total population of each of the five boroughs, as well as wider comparators:

Borough Resident Population 2018 (ONS)

Population 2028

Barnet 395,021 433,082

Camden 249,481 262,350

Enfield 339,277 373,282

Haringey 285,060 307,131

Islington 233,562 244,068

Greater London 8,980,874 9,746,735

The table indicates that the largest of numbers of people live in the boroughs of Barnet (with 395,021 people) and Enfield (with 339,277) while the least populated borough is Islington (with 233,562). The total population of the scoping area is 1.5m.

Where we refer to Lower Super Output Areas (LSOAs)please note that the average population of an LSOA in London in 2010

was 1,722 compared with 8,346 for an MSOA and 13,078 for a ward. Population Density

Figure 3 total population density of NCL

NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG's estimated population density in mid-2016 is 4831.51 per km² within a range of 96.32 to 43788 across 795 Lower Super Output Area (LSOAs). The England-wide Lower Super Output Area (LSOA) distribution is 1.71 to 72245.47 with a mean value of 3310.26 per km².

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D. Insight into protected characteristic groups

In this section each of the nine ‘protected characteristic’ groups are examined, as well considering other disadvantaged groups, specifically deprived communities and carers. This includes:

Age Disability Pregnancy and maternity Race and ethnicity Gender Sexual orientation Gender reassignment Religion and belief Marriage and civil partnership Deprived communities Carers.

For each group, we note whether there is evidence of disproportionate or differential need for elective orthopaedic services and a summary of this evidence is provided. ‘Differential need’ in the context of this report means that there is evidence that different sub sections of a protected characteristic group have different needs. For example, females and males have different needs to access a service, but there is no evidence to suggest that either females or males have a disproportionate need.

For each characteristic within scope, tables on the left-hand side of each page are provided to show the total number of that characteristic in each CCG area and the percentage of the total population. On the right-hand side of the page, socio-demographic maps are used to demonstrate the density (or distribution) of these population groups across North central London.

Larger versions of these maps are available in the appendices at page 31. In the final sections, a summary of the in-scope groups is provided alongside a commentary as to the profile of these population groups across North central London. Other equality impacts are explored, and an overview and example of potential next steps provided.

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D.1. Age (older people)

Population aged 65 or over and 75 or over:

Area Aged 65 and over

% Aged 75 and over %

Barnet 53,415 13.84 24,641 6.38

Camden 28,719 11.67 12,594 5.12

Enfield 42,030 12.68 19,491 5.88

Haringey 25,730 9.24 11,038 3.96

Islington 20,229 8.69 8,779 3.77

The analysis shows that Barnet has the highest percentage volume of those aged 65 and over and those aged 75 and over. Barnet also has significantly more older people than any of the other boroughs, with Islington having the least.

Population density aged 65 and over:

Evidence to demonstrate disproportionate need for elective orthopaedic care:

Osteoporosis, a condition treated with elective orthopaedic care, becomes more likely as we age. Around 50% of people over the age of 75 are affected by the condition, and after the age of 50 one in two women and one in five men will break a bone as a result of poor bone health arising from osteoporosis (Age UK (No date): Osteoporosis: Could you be at risk?). Evidence surrounding specialised orthopaedics services in adults also points towards older people having a disproportionate need for revision joint procedures in later life, thereby increasing the demand for elective orthopaedic care with older people. This is because the average age for

Figure 4 Population density aged 65 and over

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arthroplasty procedures is falling, and so people are likely to need revision procedures as they are having initial surgery younger. The average age for knee arthroplasty has fallen from 70.6 in 2004 to 67.5 in 2010, and from 68 in 2004 to 6.2 in 2010 for hip arthroplasty patients. It is worth noting that these figures come in a time when the population is ageing. NHS England (2013): NHS Standard Contract for Specialised Orthopaedics (Adults). 19% of women and 18% of men undergoing a total knee replacement are under the age of 60.4 Nationally the average age for total hip replacement is 68 years (British Orthopaedic Association, 2015)

Examples of evidence to demonstrate disproportionate need for elective orthopaedic care5

Older people are more predisposed to osteomyelitis than the general population as they disproportionally suffer from associated disorders (such as diabetes). (Biomed Central, 2010: Osteomyelitis in elderly patients). Bursitis also disproportionately effects older people due to the joints, muscles and tendons near the bursae being overused (NHS Choices 2014, Causes of bursitis). The NHS website reports that most people who have a total knee replacement are over 65 years old. The most common reason for knee replacement surgery is osteoarthritis. NHS Choices 2015 Changing population trends of older people Barnet has a higher proportion of its total population who are aged over 65 when compared to London. The number of people aged 65 and over is projected to increase by 34.5% by 2030, over three times greater than other age groups.

4 http://www.mtg.org.uk/major-studies/

5 Please note, that the although we are seeing a significant increase in joint replacement in the young population, it continues to be the older population that is most reliant on orthopaedic services and driving the increasing workload. Briggs, T (2015) ‘Getting it right first time’

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D.2. Disability check stats below

Population with Long term illness or disability, Learning Disabilities, Dementia, Osteoporosis and Rheumatoid Arthritis:

Area Lon

g term

illness o

r d

isability

Learnin

g

Disab

ilities

Dem

entia

Men

tal H

ealth

Osteo

po

rosis

Rh

eum

atoid

Arth

ritis

Barnet

55,302 1,469 2,887 4,140 691 1,592

Camden

17,325 744 1,363 4,002 235 1,015

Enfield

52,248 1,289 2,068 3,582 366 1,483

Haringey

39,908 1,050 1,203 3,808 298 1,158

Islington

36,435 993 1,210 3,774 170 1,021

Area 5,545 8,731 19,306 1,760 6,269 Source for Long term illness and disability: UK Census 2011) Source for Learning disability, dementia, mental health, osteoporosis and rheumatoid arthritis: QOF results year 2016/17, NHS Digital

Prevalence of Learning Disabilities across the five boroughs is lower than the England average and in line with London at an estimated 3.36 per 1000 people. The prevalence of long term conditions increases with age, in Camden for example, 60% to 65% of people aged over 55 diagnosed with a long-term condition in each locality. The prevalence of having at least one diagnosed long-term condition is highest among the black population.

Mental Health: NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG's reported prevalence of patients with mental health is 1.25% for year 2016/17. The England-wide GP distribution is 0% to 16.58% with a mean value of 0.96%. The value falls in the upper quintile. Dementia: NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG's diagnosis percentage for ages 65+ is 4.85% for January 2018. The England-wide GP distribution is 0% to 69.57% with a mean value of 4.32%. Learning disability: NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG's reported prevalence of patients with learning disabilities is 0.36% for year 2016/17. The England-wide GP distribution is 0% to 4.34% with a mean value of 0.48%.

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Examples of evidence to demonstrate disproportionate need for elective orthopaedic care

A UK report supported by the Department of Health states that people with learning disabilities may have increased prevalence of osteoporosis and lower bone density than the general population. Contributory factors include their possible lack of weight-bearing exercise, delayed puberty, entering menopause at an earlier-than-average age for women, poor nutrition, being underweight and use of anti-epilepsy medication. The report notes that people with learning disabilities have a greater prevalence of some of the risk factors associated with osteoporosis than other people (Emerson, E. et al. (2012): Health Inequalities & People with Learning Disabilities in the UK: 2012). Studies have suggested that people who take epilepsy medicine for long periods of time are at higher risk of thinning and breaking bones than those who do not take epilepsy medicine. In 2009, the Medicines, Healthcare Products Regulatory Authority (MHRA) advised that people still taking the following older epilepsy medicines on a long-term basis were at risk of osteoporosis or broken bones; Carbamazepine, Phenytoin, Primidone and Sodium valproate. However, there is little research exploring whether some of the newer types of epilepsy medicines can cause bone problems (Epilepsy Action (2013): Bone health). Epilepsy is also more common in people with a learning disability than in the general population. It is estimated that 1 in 3 people who have a mild to moderate learning disability also have epilepsy and around 1 in 5 people with epilepsy also have a learning disability. The more severe the learning disability it, the more likely that the person will have epilepsy as well (Epilepsy Society (2016): Learning disability and epilepsy). Orthopaedic surgery may also be necessary for people with cerebral palsy to correct problems with bones and joints. NHS Choices website 2015 Although there is no direct correlation between mental health and a greater need for orthopaedic surgery, those suffering with mental illness have a number of inequality issues to consider. There are three main ways, as outlined by the Department of Health DOH (2011) No Health Without Mental Health: Analysis of the Impact on Equality (AIE), that inequality is important in mental health and impacts on other areas of the report: People who experience inequality or discrimination in social or economic contexts have a higher risk of poor mental wellbeing and developing

mental health problems; People may experience inequality in access to, and experience of, and outcomes from services Mental health problems result in a broad range of further inequalities.

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Finally, there is also evidence suggesting that people with HIV may have a disproportionate need for elective orthopaedic surgery. Particularly: Low bone mineral density is prevalent in people with HIV (McComsey, GA et al (2010) ‘Bone Disease in HIV infection). Inflammatory arthropathy and avascular necrosis is common in HIV patients (Reis MD, Barcohana B, Davidson A et al. Association between human immunodeficiency virus and osteonecrosis of femoral head. J. Arthroplasty 2002; 17: 135-9). Factors that may increase the risk of osteoporosis in people living with HIV include HIV infection itself and some HIV medicines (for example tenofovir disoproxil fumarate) (Brown T, Qaqish RD Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS 20 (17): 2165-2174, 2006).

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D.3. Sex: Female

The average life expectancy at birth for each of the five boroughs according to gender and a North central London average is provided below:

Borough Females %

Barnet 195,245 49.43

Camden 122,196 48.98

Enfield 169,597 49.99

Haringey 138,001 48.41

Islington 115,700 49.54

Total 740,739

Females have been scoped in as having a disproportionate need. The evidence for this is provided below. Examples of evidence to demonstrate disproportionate need for elective orthopaedic care

Hip and knee operations have a clear role in getting patients back to work as more and more patients receiving an implant are of working age. 20% of female and 25% of male patients receiving a hip replacement are under the age of 606

6 http://www.mtg.org.uk/major-studies/

Figure 5 Population density of females in NCL

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Osteoporosis is more common in women than men. Women tend to live longer, with age leading to an increased likelihood to develop osteoporosis (see section D.1). In addition, at around the age of 50, women experience the menopause, at which point their ovaries almost stop producing the sex hormone oestrogen, which helps to keep bones strong (National Osteoporosis Society (No date): Risk factors for osteoporosis and fractures). A woman’s risk of having osteoporosis is also heightened if she has an early menopause or a hysterectomy with removal of the ovaries prior to the age of 45 (Age UK (No date): Osteoporosis: Could you be at risk?). Joint pain is a common symptom of the condition lupus, especially in the small joints found in hands and feet. The pain normally moves from joint to joint and is often described as 'flitting'. Joint pain and swelling are often the main symptoms for some people, although it is unusual for Lupus to cause joints to become permanently damaged or deformed. About 1 in 20 people with lupus develop more severe joint problems, and less than 1 in 20 have joint hypermobility or a form of arthritis called Jaccoud’s arthropathy, which can change the shape of the joints (Arthritis Research UK (No date): What are the symptoms of Lupus?). Lupus is more common in women than men, with around seven times as many women as men having the condition. Whilst drugs are often prescribed to Lupus suffers, some also undergo elective orthopaedic surgery. Up to 50% of women develop carpal tunnel syndrome (CTS) during pregnancy. CTS in pregnant women often gets better within three months of the baby being born, although it may need surgical treatment if symptoms fail to subside. In some women, symptoms can continue for more than a year. CTS is also common in women around the time of the menopause. (NHS Choices, 2014, Causes of carpal tunnel syndrome). Evidence also suggests that more women than men develop CTS, possibly because women naturally have smaller carpal tunnels (Bupa (No date): Carpal tunnel syndrome). Occasionally, some medications can also cause the condition. Exemestane and Anastrozole are both medications used for the treatment of breast cancer, thus taken by a disproportionately large number of women. Both drugs are said to potentially cause carpal tunnel syndrome (Arthritis Research UK (2012): Carpal tunnel syndrome). Finally, as women are likely to live longer than men and therefore more likely to use elective orthopaedic care (D.1.)19% of women and 18% of men undergoing a total knee replacement are under the age of 607

7 http://www.mtg.org.uk/major-studies/

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D.4. Gender Reassignment

Population demographics are not available for the numbers of people undergoing, or who have undergone, gender reassignment. However, stakeholders have noted that the number of gender reassignment procedures is increasing. This is supported by figures obtained under a Freedom of Information request, which shows that there has been increases in the number of referrals to all the UK’s gender identity clinics (GIC). The London GIC in Charing Cross is the largest adult clinic. The number of referrals has almost quadrupled in 10 years, from 498 in 2006-07 to 1,892 in 2015-16. In 2015-16, NHS England has provided an additional £3m towards funding adult GIC clinics. ‘Gender identity clinic services under strain as referral rates soar’ Guardian newspaper 10 July 2016

Examples of evidence to demonstrate disproportionate need for elective orthopaedic care

Trans men (female-to-male) and trans women (male-to-female) may be at risk of developing osteoporosis because of the need to take hormones that change the balance of oestrogen and testosterone in the body. After gender reassignment surgery, the level of hormones may decrease, and this may also affect bone density. The degree to which either of these factors affect the risk of breaking a bone, however, remains uncertain. Replacement sex hormones (testosterone for trans men and oestrogen for trans women) are necessary to maintain bone strength and are generally continued long-term. The risk of developing osteoporosis may increase if sex hormone replacement is discontinued, or if levels of replacement are too low (National Osteoporosis Society (2014): Transsexual people and osteoporosis). Research has also found that the male-to-female trans population who have their testicles removed can affect bone density as the body’s natural levels on testosterone are too low. However, evidence suggests that taking oestrogen instead compensates for the decrease in testosterone. Some trans men who are unable to take testosterone use Depo-Provera to stop their periods from occurring, and, there is some concern that using Depo-Provera can negatively affect bone density (Vancouver Coastal Health, Transcend Transgender Support & Education Society and Canadian Rainbow Health Coalition (2006): Trans people and osteoporosis). It must be noted that the research available on this issue is limited, however due to the evidence presented above, gender reassignment has been scoped in as a protected characteristic that may have a disproportionate need. This will be explored further with clinicians and representatives of those who are undergoing gender reassignment.

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D.5. Race and ethnicity: White populations

Population with a white ethnic background

Camden and Barnet have the highest volumes and proportions of people from a white ethnic background

Examples of evidence to demonstrate differential need for elective orthopaedic care

It is important to note that this report is suggesting a differential need amongst ethnic groups, rather than a disproportionate need. This is because there is evidence to suggest that those from different ethnic backgrounds have need for different types of elective orthopaedic care services. The evidence on this page highlights issues pertaining to those from a white ethnic background.

The National Osteoporosis Society states that those from Caucasian background are at higher risk of osteoporosis than Afro-Caribbean people. This is because people from an Afro-Caribbean background tend to have bigger bones. National Osteoporosis Society (No date): Risk factors for osteoporosis and fractures. See: https://www.nos.org.uk/healthy-bones-and-risks/are-you-at-risk . In addition, a US study founded that Afro-Caribbean American women’s femoral neck bone mineral density (BMD) was 10% to 25% higher when compared to US white women, thereby lessening their risk of developing osteoporosis or hip conditions in their life course (Dempster, D. et al (2013): Osteoporosis Fourth Edition). Data from a UK- cohort of the European Male Aging Study (EMAS) also compared White-British men to a group of Afro-Caribbean British and

Area Population: White ethnic background (ONS, 2011)

%

Barnet 228,553 64.13

Camden 145,055 66.29

Enfield 190,640 61.01

Haringey 154,343 60.54

Islington 140,515 68.17

England mean value NA 86.74

Figure 6 population density of white ethnicity

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South-Asian British men. The Afro-Caribbean British group had higher BMD at all sites when compared to South-Asian British and White-British, both before and after adjustment for body size (Zengin. A. et al (2015): Ethnic differences in bone health).

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D.6. Race & Ethnicity: Black populations

Population with a black ethnic background

NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS Islington CCG's population in the Black/African/Caribbean/Black British: all' ethnic group is 12.83% within a range of 0.86% to 50.59% across 795 LSOAs. The England-wide LSOA distribution is 0% to 64.96% with a mean value of 3.14%. The value falls in the upper quintile.

The population is projected to become increasingly diverse, for example, with the Black, Asian and Minority Ethnic (BAME) population in Barnet projected to increase from 38.7 to 43.6% of the total Barnet population.

Area Population: Black ethnic background

%

Barnet 81,118 12.13

Camden 18,060 8.2

Enfield 53, 687 17.18

Haringey 47,830 18.76

Islington 26,294 12.76

England mean value NA 3.14

Figure 7 population density of black ethnicity

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Examples of evidence to demonstrate differential need for elective orthopaedic care

Scientists at the London School of Hygiene and Tropical Medicine discovered that people of non-white ethnicity tend to have more severe disease and have suffered with arthritis for longer by the time they undergo surgery. (Arthritis Research UK (2012): Sociodemographic factors influence timing of joint replacement surgery). In addition, reports in the US on differences in knee osteoarthritis between African-Americans and Caucasians report a higher prevalence knee osteoarthritis in African-Americans, as well as more symptomatic knee osteoarthritis in African-Americans than Caucasians. Gait patterns can also differ between ethnic groups in osteoarthritis prevalence. A study has reported that that African-Americans were possibly more prone to lateral compartment knee osteoarthritis than Caucasians (Chaganti, R. et al. (2011): Risk factors for incident osteoarthritis of the hip and knee).

Lupus is also more common in some ethnic groups as well, particularly those of African origin (Arthritis Research UK (No date): Lupus)

Black people were one third as likely to receive a hip replacement compared to white people, while Asian people were one fifth as likely to have the procedure. For knee replacement, black people were two thirds as likely and Asian people were just over four fifths as likely to have surgery, compared to white people. Ethnic minorities are undergoing fewer than expected joint replacement operations and it is likely a combination of different factors. “One possible explanation could be patient willingness to undergo surgery amongst the different ethnic groups examined. This is often shaped by cultural factors, doctor-patient communication, and even patient trust in the healthcare system. Secondly, osteoarthritis of the hip is slightly less common amongst Black and Asian people and this may partially explain the differences. It is also interesting to note the gender differences in rates of knee replacement with Black and Asian males much less likely to undergo joint replacement than Black and Asian females. These initial observations require further investigation8

8 Smith MC, et al., ‘Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data’, Osteoarthritis and Cartilage (2017)

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D.7. Socio-economic status

Population experiencing high levels of multiple deprivation:

Using the indices of multiple deprivation, the map highlights areas of high levels of multiple deprivation with Islington and Haringey experiencing the most. Deprivation impacts life expectancy, for example, in areas of higher deprivation in Enfield, men live 8.7 years less, and women live 8.6 years less than in more affluent areas.

Examples of evidence to demonstrate disproportionate need for elective orthopaedic care

Deprivation is associated with greater need for total hip and knee replacement surgery. Moreover, more deprived patients remain in hospital longer, without morbidity, because of a lack of social support available to them in the community. (Major elective joint replacement surgery: socioeconomic variations in surgical risk, postoperative morbidity and length of stay, Journal of Evaluation in Clinical Practice, 2009)

Area Index of Multiple Deprivation score (2015)

Health Deprivation and Disability (2015)

Barnet 17.81 13.5%

Camden 26.15 13.5%

Enfield 26.99 13.5%

Haringey 31.04 13.5%

Islington 32.53 13.5%

England mean Value

21.67 NA

Figure 8 socio-economic status

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Scientists at the London School of Hygiene and Tropical Medicine also discovered that people from lower socioeconomic backgrounds, tend to have more severe disease and have suffered with arthritis for longer by the time they undergo surgery. The researchers looked at data on 117,736 patients, all of whom underwent hip or knee replacement surgery in England in 2009-10 (Arthritis Research UK (2012): Socio-demographic factors influence timing of joint replacement surgery).

Evidence suggests that malnutrition increases the risk of developing osteomyelitis, as a weakened immune system makes it more likely for infections to spread to the bones (NHS Choices, 2014, Osteomyelitis – Causes). Moreover, osteomyelitis is more likely to occur if for some reason an individual’s bones are susceptible to infection. Pre-existing health conditions, such as diabetes, can cause this. In this instance bones may not receive a steady blood supply, meaning infection-fighting white blood cells cannot reach the site of injury within the bone (NHS Choices (2014): Osteomyelitis – Causes). Diabetes prevalence increases with greater levels of deprivation. Public Health England (2014) Adult obesity and type 2 diabetes.

In addition, obesity prevalence increases with greater levels of deprivation. Public Health England (2014) Adult obesity and type 2 diabetes. Obesity is a strong risk factor for knee osteoarthritis, with obese people 14 times more likely to develop the condition than those of a healthy weight. ‘Osteoarthritis and obesity’ Arthritis Research Campaign 2013. Although the main treatments for osteoarthritis include lifestyle measures, in some cases, surgery to repair, strengthen or replace damaged joints is preferred.

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D.8. Carers

Number of people providing care per week across the five boroughs (Census 2011)

Barnet has a significantly higher volume of carers than any other area, however Enfield has proportionately more individuals caring for another person for over 50 hours a week.

Please note that whilst the most up-to-date data on carers is from the 2011 census, figures may have changed since then. In addition, carer figures tend to be under-reported as data requires carers to self-identify. A proportion of those whom the NHS would deem to be carers do not identify themselves in this way.

Examples of evidence to demonstrate differential need for elective orthopaedic care

It is important to note here that we are not stating carers have a disproportionate need for elective orthopaedic care, rather they have a differential need due to their caring responsibilities, which is different to non-carers. As older people are more likely to require carers, and they are the greatest users of elective orthopaedic care, carers are likely to be impacted by any service changes. A report by Carers UK indicated that failing to consider post-hospital support and carers’ needs had counterproductive consequences, such as increased readmission (Carers’ UK, 2016: Response to the Public Administration and Constitutional Affair Committee Inquiry into Unsafe Hospital Discharge). Carers can also be disproportionate affected by longer waiting and recovery times for surgery, fitting this around the needs of those they care for is a delicate balance.

Area Carers providing 1-19 hours care per week

20-49 hours

50+ hours

Barnet 21,448 5584 6224

Camden 11,551 2457 3318

Enfield 17,299 4131 6194

Haringey 11,812 2904 4171

Islington 10,044 2505 3762

Area 72,154 17581 23669

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E. Summary of Scoped in Groups

The table below gives a summary of the groups scoped in and whether they have a disproportionate or differential need for elective orthopaedic care. For each group, we note whether there is evidence of disproportionate or differential need for elective orthopaedic services and a summary of this evidence is provided. ‘Differential need’ in the context of this report means that there is evidence that different sub sections of a protected characteristic group have different needs. For example, females and males may have different needs to access a service, but there is no evidence to suggest that either females or males have a disproportionate need.

Characteristic Disproportionate need Differential need

Age: Young people

Age: Older people

Disability

Gender: Female

Gender: Male

Gender reassignment

Marriage and civil partnership

Pregnancy and maternity

Race and ethnicity: White

Race and ethnicity: Black

Religion and belief

Sexual orientation

Deprivation

Carers

It is important to note that the report is not suggesting that other groups will not have need of these services, rather it is to suggest that there does not presently exist a body of evidence indicating a disproportionate or differential need. This can and should be, continually examined through any potential further stages of the process.

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F. Summary of the geographical distribution of ‘scoped in’ groups

At the CCG level, volume and proportion are used as helpful measures to understand the population of each scoped in group and to understand the relative presence of any particular group.

At a pan Central North London level, it is useful to look at density as a measure by which to understand where the greatest concentration of scoped in groups are located. This is important because this helps to indicate where impacts, both positive and negative, are more likely to be realised across the study area without the analysis confined to administrative boundaries.

In the case of this equality analysis and its ability to inform the decision-making process, it is crucial to look at future service provision across Central North London, rather than at a CCG level. Travel time and accessibility impacts will need to be considered in any future analysis, particularly as sites are selected to deliver more or less elective activity. Data on how populations are changing has been excluded from this analysis.

Scoped in groups Volume Proportion Highlight comments

at CCG level Density Highlight comments at North

central London level

Age (Older people) Barnet has the highest

numbers of those aged

65 or over and aged 75

or over. Enfield also has

high volumes.

The greatest proportions of

older people are in Barnet

(13.84%) and Enfield (12.68%),

both of which are slightly

higher than the greater London

average (12%).

Barnet and Enfield

are areas with high

volumes and

proportions of

older people.

Density of older

people is highest

in areas of Barnet

and Enfield.

The north west of the study area

has the highest density of older

people.

Disability Barnet has the most

people living with a long-

term illness or disability.

Camden has the lowest volume

As a proportion of the

population, greater

proportions of disabled

people are in Islington

(15.6%), Enfield (15.4%) and Camden

(14.4%), all of which are slightly

higher than the greater London

average (14%)

Barnet has high

volume and

proportion of those

living with a long-

term illness or

disability. Camden

and Islington have

higher proportion of

those living with

mental ill health.

Islington and

Camden have higher

densities of those

with a long-term

illness or disability,

The inner London boroughs in the north west of the study area have the highest density of those with a long-term illness of disability.

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Gender: Female

Continued…

Scoped in groups Volume Proportion Highlight comments at a CCG

level Density Highlight comments at Central

North London level

Race & ethnicity:

White

Barnet has the greatest

volume of people from

a white ethnic

background.

Islington (68%), Camden

(66%) and Barnet (64%)

have the highest

proportion of people

from a white ethnic

background.

Barnet has the highest volume

and one of the highest

proportions of people from a

white ethnic background.

Islington has the highest

density of those from a white

ethnic background, Enfield

the lowest.

Pockets of high density of

people from a white ethnic

background exist across the

study area.

Race and ethnicity:

Black The greatest volume of

black communities is in

Barnet, followed by

Enfield and then

Haringey.

Haringey (19%) and

Enfield (17%) have the

highest proportion of

people from a black

background.

Barnet has the highest

volume, and Haringey, has the

highest proportion, of those

from a black background.

The greatest densities people

with a black background is in

Haringey.

Pockets of high density of

people with a Black ethnic

background exist across the

study area.

Gender reassignment

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Deprived communities The volume of people

classified as deprived is

far greater in Islington

and Haringey.

According to the GLA

report on Indices of

Deprivation in the

capital There is a

crescent of deprivation

from Enfield south

through Haringey to

Islington, Camden and

Hackney

Islington (32.53) and

Haringey (31.04) also

have the highest levels

of deprivation, both of

which are significantly

higher than the greater

London average and

national average (see

appendix 8).

Enfield and Camden have very

high volumes and proportions

of people classified as

deprived.

Islington has higher densities

of deprivation, though

pockets also exist in Haringey

and Camden

The central of the study area

has the highest density of

people living in deprivation.

Carers Barnet has the largest

volume of carers and is

much higher than the

other areas.

Barnet has the highest

proportion of carers,

though all are similar or

identical to that of the

greater London average

of 5%

Barnet has significantly more

carers than any other area. It

is also has the highest

proportion of carers. This is

consistent with the fact that

Barnet also has the largest

volumes of older people.

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G. Concluding observations

Equalities analysis

This scoping report highlights the need for the following groups to be included in any potential future engagements or if there is a need for consultation efforts; older people, disabled people, females, people undergoing gender reassignment, people from a white ethnic background, people from a black background, people in economic and social deprivation and carers.

It is understood that disability is a heterogeneous category and that people with different disabilities have different needs. This report focuses on those with learning disabilities, rheumatoid arthritis, osteoporosis, epilepsy, mental health issues or dementia as this is where most recent evidence exists to demonstrate disproportionate need. This will be further explored with stakeholders representing disability as engagement continues.

It should be noted that individuals may be represented by more than one of the protected characteristics as scoped in this report. This does not mean that their need would be greater than an individual with one of the protected characteristics scoped in to our report. For example, a woman over 65 falls in to two of the protected characteristics (women and people over 65) we cannot quantify that this example has double the level of need as a woman under 65.

Recommendations for future engagement and consultation

Previous related consultation efforts have picked up on the following areas of focus that might highlight variation in access, quality and outcomes relevant to equalities should any potential plans require a consultation process:

Location of rehabilitation services Liaisons between community care services and planned care centres How planned care centres meet requirements of people with specific needs. This will emerge throughout the engagement process.

As part of planning, along with any potential future engagement or consultation processes, the report suggests that NLP considers examining issues such as; the location and access of services, the design of services monitoring and feedback. This will assist NLP in understanding how factors such as location, the design of service and how they capture feedback is important to patients and stakeholders. This is to be discussed further with NLP should there be a need to move in to a public consultation phase.

The social demographic analysis demonstrates difference in population groups across the five boroughs represented by the NLP. Northern parts of the area represented by the STP, Barnet and Enfield, have higher densities of the older people and carers. More central boroughs, Camden and Islington, have

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higher densities of long term disability or deprivation. If NLP proceed to consultation phases it will be prudent to focus consultation activities on certain groups in specific areas according to the trends identified in the report.

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H. Next steps

Recommendations for current engagement and potential consultation)

A continuing programme of engagement, these could take the form of face-to-face meetings, one-to-one telephone interviews with stakeholders, focus groups and presentations

To date stakeholders have highlighted some potential overarching equality impacts, which we will look to explore in more detail in any further stages, Patient experience and quality of care: Some vulnerable groups find it more challenging to understand and accommodate change in service provision,

either due to challenges in terms of comprehension, anxiety around unfamiliar journeys or venues and/or a lack of independence. This may affect patient experience before and during service receipt.

Travel and access for certain protected characteristic groups: Centralisation of some services will require longer journey times for some patients. Understanding the extent to which these longer journey times affect the protected characteristics will be critical. This is particularly the case because several equality groups have a higher reliance on public transport than the general population which can compound any accessibility impacts. It is recommended that NLP might want to consider this issue quantitatively using travel and access analysis, based on different service options. We can discuss the benefits of this with NLP in more detail

Providing expert advice to NLP during any potential public consultation phase. Undergoing staff engagement through one-to-one interviews. Delivering an equalities training workshop to NHS staff on the data required to fulfil Public Sector Equality Duty (PSED).

Recommendations for service design Equalities recommendations should be considered at every stage of the service design Equalities monitoring whether through PSED2 or other mechanism should be built into contract monitoring Commissioning of insight work to address gaps in equality data and information about vulnerable and isolated groups Collaboration with partner agencies to share information around particular groups to strengthen and consolidate data capture and analysis. Introduction of key equality questions at each stage of any procurement process to ensure a stronger emphasis on provider requirement to provide

specific responses tailored to population. Collaboration with system partners to agree more specific equality outcomes measures are supported by co-ordinated action by other partner

organisations which address the wider determinants that impact on health outcomes. More comprehensive equality analysis and recommendations for best practice to be written into equality analyses and provided as an important

addendum for providers to drive service change. Building in a more explicit requirement for potential providers to evidence their ability to flex and sustain required changes in services in light of new

and existing changes to equality data and population need.

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I. APPENDICES – Larger versions of maps

1. Elective commissioner activity by Healthcare Resource Groups (HRG)

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2. NCL Population Density

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3. Population Density – Over 65

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4. Population Density – Sex: Female

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5. Population Density – White Ethnicity

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6. Population Density – Black Ethnicity

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7. Socio-economic Status

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Deprivation score – Index of Multiple Deprivation 2015

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1 Source: Department for Communities and Local Government (DCLG) 2015