Appendix 2

EIA/ Due Regard Assessment Tool

To be completed and attached to any policy when submitted to the appropriate committee for consideration and approval.

Proposed Colorectal Cancer Surgery Relocation from Royal Sussex County Hospital to Worthing General Hospital

		Yes/No	Comments
1.	Does the document/guidance affect one group less or more favourably than another on the basis of:
	· Age	Yes	94% of new bowel cancer cases are identified in patients over 50 years of age.  Older patients are therefore disproportionally affected. However the proposed change will improve treatment by reducing cancellations, reducing LoS and providing earlier stoma reversals.  These will positively impact over 50s as reduced stays will reduce deconditioning and earlier stoma reversals will assist rehabilitation
	· Disability	Yes	All patients impacted by the move will have cancer and therefore will be considered as disabled. Moving the location of surgery will improve the access to treatment which will serve all patients better.  Access to patient transport assistance policy will serve to mitigate challenges rising from the relocation. Reduction in surgery cancellations will reduce impact on carers as well as patients as they won’t need to change their plans at short notice.  In addition to being less stressful on patients, reduced cancellations will improve the situation for family.
	· Gender (Sex)	No	1 in 17 men and 1 in 20 women are diagnosed and therefore there is little difference in impact between sexes
	· Gender Identity	Yes	In the USA, data shows that Colon cancer screening (CRC) rates are lower in transgender (TGD) people compared to cis-gender people. Studies have identified several barriers to screening. TGD people experience discrimination such as unemployment, lack of education, access to health care, housing insecurity. This impacts patients at the diagnosis stage as they are less likely to come forward for screening.  It is reasonable to assume that this disparity may also exist in the UK and that patients may present later with more complex cancer. The colorectal cancer service relocation is focused on the patients post diagnosis.  Once diagnosed we would expect the impact of gender identity to be reduced as they would have come forward for treatment. The Trust’s trans gender guidelines will be followed as for all patients. The Trust has two policies that address transgender patients that are applied consistently across all hospitals: Privacy, dignity and respect policy, and Policy for the provision of same sex accommodation.
	· Marriage and civil partnership	No
	· Pregnancy and maternity	Incredibly rare but possibly	A case every 5 years might occur therefore this is so rare that this should not impact the service move consideration
	· Race (ethnicity, nationality, colour)	Probably	There is documented evidence in the US that race and socioeconomic status has a negative impact on colorectal cancer outcomes.  Patients present later with more complex cancer. The data is US focused, complex and is impacted by patients having inadequate healthcare insurance that is different to the UK. That said cancer research UK highlights that rates of bowel cancer are lower in Asian and black ethnic groups. The colorectal cancer service relocation is focused on the patients post diagnosis.  Once diagnosed we would expect the impact of race to be reduced.  However, the impact of travelling slightly further may impact more frequently those in a lower socioeconomic cohort.  This can be lessened through access to the Patient transport provisions, as these patients would most likely be eligible for assistance.
	· Religion or Belief	yes	There is research that suggests prevalence of colorectal cancer in some religions is lower than the wider population.  However, religious and cultural differences may affect how a patient feels about having a stoma. For some people, these beliefs can make it harder to adjust to life with a stoma.   This can be mitigated through post-surgery individual care from stoma nurses and therefore concerns can be mitigated.
	· Sexual orientation, including lesbian, gay and bisexual people	Yes	Colorectal cancer disproportionately affects the LGBTQ+ community for a number of reasons, including fear of discrimination and other lifestyle factors. The colorectal cancer service relocation is focused on the patients post diagnosis.  Once diagnosed we would expect the disparity of impact for the LGBTQ+ community to be reduced.
2.	Is there any evidence that some groups are affected differently and what is/are the evidence source(s)?	Yes	Overcoming Racial and Ethnic Disparities in Rectal Cancer Treatment | Colorectal Cancer | JAMA Network Open | JAMA Network Racial and Ethnic Disparities in Colorectal Cancer Incidence and Mortality - PMC (nih.gov) Services | The Rose Thompson Foundation (rosetf.org.uk) Bowel cancer statistics | Cancer Research UK Let's talk about...LGBTQ+ in cancer research - Cancer Research UK Manchester Centre Cancer Risks for Gay and Bisexual Men - Health Encyclopedia - University of Rochester Medical Center Having a stoma | Bowel cancer | Cancer Research UK Religious beliefs, practices, and health in colorectal cancer patients in Saudi Arabia - Shaheen Al Ahwal - 2016 - Psycho-Oncology - Wiley Online Library
3.	If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?	Yes	The objective of the relocation of colorectal cancer surgery is to improve outcomes for patients. The clinical benefits would be significant -Cancellations, especially multiple cancellations would be reduced, minimising the likelihood of harm being caused. -Length of stay would be nearly halved through the enhanced recovery model delivered at Worthing -Length of Stay for stoma reversals reduced by 37% -Access to stoma reversals would be in line with national guidelines at 6 months (where appropriate).  Currently they are delivered in a 12-18 month timeline. The enhanced recovery model that is offered to patients at Worthing drives the earlier discharges.  This is a model that results in earlier planning for discharge and interventions during the hospital stay.  This will be especially beneficial to patients with protected characteristics. Pre-surgery consultations and post-surgery follow up is planned to be offered at the home hospital, so primary impact would be on patient during the period of receiving surgery
4.	Is the impact of the document likely to be negative?	No	Some patients will experience a longer journey to and from the hospital that will perform surgery.  This should be a single extended journey distance.  Visting families and friends could also experience this longer travel distance, but it would be for a shorter time as length of stay will be reduced. If the patient is also a carer, then the significantly reduced length of stay has the opportunity to reduce the impact if the surgery.
5.	If so, can the impact be avoided?	Mitigated	All patients will have access to the Trusts’ patient transport offering. Not all patients are aware of the offering and therefore at the point that patients are offered surgery the patient transport offering could be proactively communicated. It is the recommendation of the Trust’s EDI team that clear details of the patient transport policy be made available in the documentation issued to these patients about their surgery.
6.	What alternative is there to achieving the intent of the document without the impact?	None	There is very little opportunity for an alternative approach. There is a current demand for 141 sessions in general theatres compared to a maximum capacity of 120 sessions.  This does not factor in any growth. Due to these theatre capacity constraints at the county site and emergency surgery taking priority over elective there is little opportunity to reduce cancellations for this cohort of patients without the service move.  Building additional theatres is not a short-term possibility and would be extremely challenging on the Brighton campus, therefore moving surgery for some specialties off the RSCH site is the most effective way to address this constraint.
7.	Can we reduce the impact by taking different action and, if not, what, if any, are the reasons why the policy should continue in its current form?	Yes	See above
8.	Has the document been assessed to ensure service users, staff and other stakeholders are treated in line with Human Rights FREDA principles (fairness, respect, equality, dignity and autonomy)?	Yes	This document has been reviewed and discussed with the Trust’s EDI team. Recommendations from the team have been incorporated into the EHIA.

If you have identified a potential discriminatory impact of this policy, please refer it to the Trust’s EDI lead, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact uhsussex.equality@nhs.net (01273 664685).