Equality Impact Assessment Tool for Frontline Patient Services

Equality Impact Assessment is a legal requirement and may be used as evidence for cases referred for further investigation for legislative compliance issues. Please refer to the EQIA Guidance Document while completing this form. Please note that prior to starting an EQIA all Lead Reviewers are required to attend a Lead Reviewer training session. Please contact [email protected] for further details or call 0141 2014560.

1. Name of Current Service/Service Development/Service Redesign:

Breast Service Review

This is a : Service Redesign

2. Description of the service & rationale for selection for EQIA: (Please state if this is part of a Board-wide service or is locally determined).

A. What does the service do?

The NHSGGC Breast Service provides diagnosis and treatment of symptomatic and non symptomatic breast disease. In recent years the service has seen a 30% increase in referrals but no increase in the prevalence of diagnosed disease. This has lead to a marked increase in the demand for outpatient consultation and radiological imaging which the service has struggled to meet with the limited capacity available.

B. Why was this service selected for EQIA? Where does it link to Development Plan priorities? (if no link, please provide evidence of proportionality, relevance, potential legal risk etc.)

The Breast Service review is part of the 2017-18 Local Delivery Plan and is identified as a clinical area of priority for redesign. Issues to address The planning assessment and supporting clinical opinion highlighted a series of issues which generated the conclusion that the current breast service was not capable of delivering the sustainable high quality patient service that was required. Strategic Service Delivery: The NHSGGC CSS and National clinical Strategies both focus on the delivery of treatment from ambulatory care facilities whenever possible and the use of centralised centres of excellence to improve the clinical outcomes for lower volume higher complexity work. The patient focus group stated that speed and quality of treatment and continuity of care from a team they trusted outweighed any preference for a particular hospital site. Demand and Capacity: The breast service has seen a 30% increase in referrals in recent years but no appreciable difference in the incidence of cancer or the need for treatment resulting from the increase in referrals. In order to meet the increased demand for outpatient 2015-16 the breast service waiting time was maintained by the use of a high number of waiting list initiatives. Multi Site Working: The breast team in Clyde cover 3 sites and in the South the breast team operate as 2 sub teams split across GGH and the Victoria ACH. This covering across or split between sites leads to difficulty in delivering continuity of care on each site, the ability to cross cover during leave or absence and minimises the time during which the team are together on a single site which hampers team building and knowledge sharing. Consistent Alignment of Radiology Resource: There is a national shortage of breast radiologists and a high proportion of those in post are approaching retirement. Recruitment into vacant breast radiology posts is challenging as there is a perception that the specialty is under pressure. Even with an extension in the role of the existing radiographers there is a serious shortfall in the available skilled workforce in the next 3-5 years. A one stop shop high risk clinic requires the sustainable coordination of the breast team and diagnostic support. The mammography equipment at IRH and the VOL date back to 2001 and that at RAH has been in service since 2007. The IRH and VOL machines are only in use for a maximum of 3 sessions per week. Availability of Specialty Doctors: In recent years the breast service has been supported by the use of specialty doctors. There is now a real challenge in filling these posts which is driving a need to look at alternative and enhanced roles for nurses. Considerations and proposed actions to deliver the change Demand Management and Risk Stratification: In order to address the imbalance between patients referred into breast services and those requiring treatment a review of the referral criteria in place for breast services was conducted and new guidelines developed. These criteria are to be supported by increased education for primary care regarding these criteria and improved processes for the compliance with these criteria. A move to the new criteria has been piloted in Clyde where there has already been a 9% decrease in referrals in 2016 and the full effect of the change is estimated at up to 30%, which would substantially reduce the need for waiting list initiatives to manage waiting times. Also piloted with success in Clyde has been the adoption of a stratification of breast referrals into high risk one stop shop and low risk clinics. This model is now being put in place across GGC. Standardisation of Administration Processes: Within the current model high risk surgical patients from the North and South sectors are admitted to RAH where they have access to critical care facilities. The transfer of patients between sectors either due to clinical risk or to maximise the use of all available capacity is far more efficient if there are standardised administration processes across NHSGGC. Team working within the Breast Sectors: The rationalisation of breast teams onto fewer sites in each sector allows the development of a closer team approach favoured by the patient panel, an increased ability to cross cover, a concentration of the diagnostic resource and the synergies and economies of scale inherent in bringing more volume through fewer sites. Coordination with oncology and Plastic Surgery: Having the breast service rationalised onto fewer sites also makes coordination of the interfaces with the outreach services from oncology and plastic surgery more efficient. Development of an optimised service site configuration The Breast Review Steering Group agreed in December 2016 that a comprehensive options development and appraisal process would be the best way to come to an agreement on the best service configuration to deliver sustainable high quality patient care. A series of possible site configurations were developed and criteria against which to judge each option were also weighted in terms of importance and agreed. The various site options and the scoring criteria are shown in the Tables below. Table 1: Site Configuration Options Table 2: Options Scoring Criteria During the early months of 2017 each sector and directorate conducted an engagement process with all members of the wide clinical team in order to discuss the various options and to assess the deliverability and sustainability of each option including the effect on patient experience and service quality. It was also during this time that the patient focus group was convened and the patient agreement gained on the criteria to be used in the options appraisal and the relative weighting. Following this comprehensive engagement each sector or directorate was invited to be represented by a senior clinician and manager at the options scoring. Each sector or directorate team were given an opportunity to make a short presentation on their view on the case for change and then each representative scored each option against the agreed weighted criteria. Another short presentation was given summarising the output of the patient focus group to ensure the scoring representatives took the patient opinion into account. The summary of the scoring is shown in the table below. Table 3: Options Scoring Summary Option 8 is scored as the best option against all the criteria with the exception of Patient Convenience where option 9 scores best but this option scores badly on the other criteria. THE PREFERRED CONFIGURATION The result of the options scoring was a very strong preference for Option 8 from all the sectors and directorates represented. This configuration would see no appreciable change to the service in the North where 95% of the service is already delivered form a single ambulatory care hospital and high risk patients are seen at the RAH and joint cases with plastics are seen at the GRI. In South Glasgow this configuration would see a stratification of the outpatient service to one stop shops delivered at GGH only and surgery requiring localisation being delivered only at GGH. This configuration is intended to allow maximum rationalisation of the available diagnostic resource. The exact clinic and theatre configuration will be developed in partnership with diagnostics to achieve this optimisation. It should be noted that there was an agreement in the South team that the optimal configuration would be to reconfigure onto a single site but that in the short term this was undeliverable owing to the lack of sufficient capacity on either of the South sites. In Clyde the new configuration would see the consolidation of all breast outpatient, day case and inpatient work centralised onto the RAH site Political considerations It is recognised that any reconfiguration of services away from the IRH and VOL in particular is likely to generate local political interest. The Clyde team have considered this when making their case for change and there is agreement amongst the breast consultants, wider breast team and senior leadership team that this proposed rationalisation is the best option for delivering sustainable high quality patient care. The robust case for change made by the Clyde team centred on the following considerations. Deliverability: Outline provision has been identified to provide the additional clinic space required, the theatre resource is already in place. Sustainability: The new consolidated service has the capacity to see 100 one stop patients per week in base capacity removing the need for WLI. The new service would allow greater cross cover to provide a consistent service level through leave and absence periods. The new service makes better use of the limited diagnostic equipment and radiologist and radiographer resource Quality: The new consolidated service would improve continuity of care and allow a more integrated breast team to develop the identity the patient focus group wished to see.

3. Who is the lead reviewer and when did they attend Lead reviewer Training? (Please note the lead reviewer must be someone in a position to authorise any actions identified as a result of the EQIA)


Date of Lead Reviewer Training:

Sillers, Barry

4. Please list the staff involved in carrying out this EQIA (Where non-NHS staff are involved e.g. third sector reps or patients, please record their organisation or reason for inclusion):

Susan Groom (General manager); McFadyen, Susan (General Manager); Smart, Jacki (General Manager)

Lead Reviewer Questions

Example of Evidence Required

Service Evidence Provided

Additional Requirements


What equalities information is routinely collected from people using the service? Are there any barriers to collecting this data?

Age, Sex, Race, Sexual Orientation, Disability, Gender Reassignment, Faith, Socio-economic status data collected on service users to. Can be used to analyse DNAs, access issues etc.

Patient records covering age sex and other demographic information has been used in the review.


Can you provide evidence of how the equalities information you collect is used and give details of any changes that have taken place as a result?

A Smoke Free service reviewed service user data and realised that there was limited participation of men. Further engagement was undertaken and a gender-focused promotion designed.

As part of the review a patient focus group was convened to seek patients views and to record any inequality issues. The group had members from both genders and a range of ages and social status. No inequality issues were raised.


Have you applied any learning from research about the experience of equality groups with regard to removing potential barriers? This may be work previously carried out in the service.

Cancer services used information from patient experience research and a cancer literature review to improve access and remove potential barriers from the patient pathway.

The geographical diversity of the patient catchment for breast services was raised. Patients placed quality and speed of treatment above local access but requested late morning appointments when traveling form distance.


Can you give details of how you have engaged with equality groups to get a better understanding of needs?

Patient satisfaction surveys with equality and diversity monitoring forms have been used to make changes to service provision.

As part of the review a patient focus group was convened to seek patients views and to record any inequality issues. The group had members from both genders and a range of ages and social status. No inequality issues were raised which merited further surveys to be completed.


Question 5 has been removed from the Frontline Service Form.


Is your service physically accessible to everyone? Are there potential barriers that need to be addressed?

An outpatient clinic has installed loop systems and trained staff on their use. In addition, a review of signage has been undertaken with clearer directional information now provided.

The OP and Theatre complexes are accessible.


How does the service ensure the way it communicates with service users removes any potential barriers?

A podiatry service has reviewed all written information and included prompts for receiving information in other languages or formats. The service has reviewed its process for booking interpreters and has briefed all staff on NHSGGC’s Interpreting Protocol.

Staff are aware and the patient focus group were very complementary about staff communication and the access to support provided.


Equality groups may experience barriers when trying to access services. The Equality Act 2010 places a legal duty on Public bodies to evidence how these barriers are removed. What specifically has happened to ensure the needs of equality groups have been taken into consideration in relation to:



A sexual health hub reviewed sex disaggregated data and realised very few young men were attending clinics. They have launched a local promotion targeting young men and will be analysing data to test if successful.

The majority of breast service patients are women, however men gain access to the service when required in the same process as women. The male patient at the patient focus group considered that he was treated equally and to a very high standard.


Gender Reassignment

An inpatient receiving ward has held briefing sessions with staff using the NHSGGC Transgender Policy. Staff are now aware of legal protection and appropriate approaches to delivering inpatient care including use of language and technical aspects of recording patient information.

The breast service provides treatment to Gender Reassignment patients and staff are familiar with this patient cohort.



A urology clinic analysed their sex specific data and realised that young men represented a significant number of DNAs. Text message reminders were used to prompt attendance and appointment letters highlighted potential clinical complications of non-attendance.

There are no age cut offs.



An outpatient clinic reviewed its ethnicity data capture and realised that it was not providing information in other languages. It provided a prompt on all information for patients to request copies in other languages. The clinic also realised that it was dependant on friends and family interpreting and reviewed use of interpreting services to ensure this was provided for all appropriate appointments.

Patients information is available in a range of languages and staff are aware of the need for and availability of interpreting support.


Sexual Orientation

A community service reviewed its information forms and realised that it asked whether someone was single or ‘married’. This was amended to take civil partnerships into account. Staff were briefed on appropriate language and the risk of making assumptions about sexual orientation in service provision. Training was also provided on dealing with homophobic incidents.

There is no reason why breast disease should be influenced by sexual orientation.



A receptionist reported he wasn’t confident when dealing with deaf people coming into the service. A review was undertaken and a loop system put in place. At the same time a review of interpreting arrangements was made using NHSGGC’s Interpreting Protocol to ensure staff understood how to book BSL interpreters.

No barriers to access have been identified in the service review.


Religion and Belief

An inpatient ward was briefed on NHSGGC's Spiritual Care Manual and was able to provide more sensitive care for patients with regard to storage of faith-based items (Qurans etc.) and provision for bathing. A quiet room was made available for prayer.

Staff are aware of and apply the relevant policies.


Pregnancy and Maternity

A reception area had made a room available to breast feeding mothers and had directed any mothers to this facility. Breast feeding is now actively promoted in the waiting area, though mothers can opt to use the separate room if preferred.

No barriers to access have been identified in the service review.


Socio - Economic Status

A staff development day identified negative stereotyping of working class patients by some practitioners characterising them as taking up too much time. Training was organised for all staff on social class discrimination and understanding how the impact this can have on health.

No barriers to access have been identified in the service review.


Other marginalised groups - Homelessness, prisoners and ex-offenders, ex-service personnel, people with addictions, asylum seekers & refugees, travellers

A health visiting service adopted a hand-held patient record for travellers to allow continuation of services across various Health Board Areas.

No barriers to access have been identified in the service review.


Has the service had to make any cost savings or are any planned? What steps have you taken to ensure this doesn’t impact disproportionately on equalities groups?

Proposed budget savings were analysed using the Equality and Human Rights Budget Fairness Tool. The analysis was recorded and kept on file and potential risk areas raised with senior managers for action.

The service redesign will improve access to breast services for all groups.


What investment has been made for staff to help prevent discrimination and unfair treatment?

A review of staff KSFs and PDPs showed a small take up of E-learning modules. Staff were given dedicated time to complete on line learning.

Staff are trained to the required level for their grade and position and aware of and apply the relevant policies.

11. In addition to understanding and responding to our legal responsibilities under the Equality Act (2010), services have a duty to ensure a person's human rights are protected in all aspects of health and social care provision. This may be more obvious in some areas than others. For instance, mental health inpatient care (including dementia care) may be considered higher risk in terms of potential human rights breach due to removal of liberty, seclusion or application of restraint. However risk may also involve fundamental gaps like not providing access to communication support, not involving patients/service users in decisions relating to their care, making decisions that infringe the rights of carers to participate in society or not respecting someone's right to dignity or privacy.

Please give evidence of how you support each article, explaining relevance and any mitigating evidence if there's a perceived risk of breach. If articles are not relevant please return as not applicable and give a brief explanation why this is the case.

Right to Life

Patients are fully involved in their treatment decisions.

Everyone has the right to be free from torture, inhumane or degrading treatment or punishment

The breast service review did not find any cases of torture, inhumane or degrading treatment or punishment.

Prohibition of slavery and forced labour

No one is the breast service has been forced to work as a slave.

Everyone has the right to liberty and security

No patients or staff are kept in detention.

Right to a fair trial

There is a robust complaints procedure in place.

Right to respect for private and family life, home and correspondence

Families and carers are involved in supporting the decision making of patients where appropriate.

Right to respect for freedom of thought, conscience and religion

The breast service delivers treatment regardless of religion or belief.


No discrimination was found or reported during the service review.

12. If you believe your service is doing something that ‘stands out’ as an example of good practice - for instance you are routinely collecting patient data on sexual orientation, faith etc. - please use the box below to describe the activity and the benefits this has brought to the service. This information will help others consider opportunities for developments in their own services.