APPENDIX 3 ATT D. Equalities Analysis - Choosing Wisely. Name of policy/function/service development being assessed: Choosing Wisely

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1 ATT D APPENDIX 3 Equalities Analysis - Choosing Wisely Name of policy/function/service development being assessed: Choosing Wisely Briefly describe its aims and objectives: The CCG has decided that in order to get best value from their commissioning expenditure they are going to consider these areas of commissioning: IVF and specialised fertility services Prescriptions for: Gluten free foods Vitamin D Baby milk Self-care medications Lead officer: Tonia Michaelides, Managing Director, Kingston & Richmond CCGs Person completing this EIAs: Hannah Keates - Engagement & Equalities Lead, Kingston CCG and Caroline O Neill Engagement & Equalities Lead, Richmond CCG with the support of the Richmond public health team. Why is the equality analysis being undertaken? To ensure we provide services in accordance with the Equality Act 2010 and fulfil our statutory responsibility under the Public Sector Equality Duty 2011; and to ensure there are no adverse changes for people with protected characteristics as a result of the decommissioning proposals. The nine protected characteristics are: Age, disability, gender reassignment, marriage & civil partnership, pregnancy & maternity, race, religion or belief, sex, sexual orientation. This equality analysis is being completed based on demographic data, past relevant surveys and qualitative feedback. We will then use the information gathered during the consultation to ensure that the Governing Bodies are fully informed about the impacts of the proposals. 1. Prescriptions for gluten free food

2 The NHS has provided a range of staple gluten free foods on prescription to patients suffering from coeliac disease for over 30 years. Coeliac disease is an autoimmune disorder that involves a heightened immunological response to ingested gluten in genetically susceptible people. Individuals diagnosed as having coeliac disease need to follow a strict gluten free diet. Gluten free products are currently able to be prescribed on the NHS for specific indications in line with the Advisory Committee for Borderline Substances recommendations. Coeliac disease is a common condition that affects approximately 1 in every 100 people in the UK. Reported cases are two to three times higher in women than men. It can develop at any age, although symptoms are most likely to develop during early childhood (between 8-12 months old) and in later adulthood (between years of age). People with certain conditions including type 1diabetes and autoimmune thyroid disease have an increased risk of getting coeliac disease. (NHS Choices website) In a recent NICE briefing paper they highlighted a prevalence of 1 in 100, or an overall prevalence in England of 530,000 people. A recent study found an incidence rate of 13.8 per 100,000 person-years for coeliac disease between in the UK. (Gujral N et al Celiac disease, World J Gastroenterol, 2012, Nov 14) Based on the available information of a prevalence of % and a GP registered population of 202,397 it may be expected for Kingston to have between 304 2,024 individuals with the disease, and roughly 28 new cases per year (based on the estimate of a 13.8 incidence per 100,000 person years). Currently Kingston CCG spends 46,000 on gluten free products every year. What engagement & consultation has been used? The CCG ran Choosing Wisely engagement between 15 March and 14 July 2017 (including a pause for the general election purdah from 20 April 8 June) to gather the views of local people about the proposals. The engagement document asked for feedback on these areas as well as asking if respondents had any concerns about the proposals, whether there should be any specific exemptions and if there were any other comments that should be taken into consideration. Over 200 were received and the survey results relating to gluten free food show that 61% strongly agreed or agreed and 39% disagreed or strongly disagreed that the local NHS should stop prescribing gluten free foods. There was strong support for this proposal however the main areas of concern if this proposal were to be taken forward are: Maintaining a gluten free diet Concerns were raised about if people with coeliac disease would be able to maintain a gluten free diet if products were no longer available on prescription. Respondents pointed out that adherence to a gluten free diet is the only complete medical treatment for coeliac disease.

3 Issue of being able to trust products on prescription as these are considered to be of a higher quality and with different amounts of fat and sugar compared to those available in the supermarkets. Respondents commented that supermarket gluten free products are unpalatable and may not always be safe; ie potential for gluten contamination. Some support for continuing to prescribe staple food items only (for example bread, cereals and pasta). Long term impact of removing access to gluten free foods on prescription The long term impact of not adhering to a strict gluten free diet in terms of health risks including osteoporosis and bowel cancer, which would impact on a patients quality of life and for the NHS the increased cost of treating these consequences. The British Specialist Nutrition Association (BSNA) advised that many people with coeliac disease highlight that receiving gluten free products on prescription was an important factor in helping them adhere to treatment. Pricing and availability of gluten free foods Many of the respondents commenting on the gluten free proposals highlighted the cost of gluten free foods and lack of easy access to them. Respondents said that the cost of these products is not that cheap and tends to be 3-4 times the cost of non-gluten free equivalent items in the supermarket. Also that gluten free food is not readily available in convenience stores and smaller supermarkets, and that the gluten free food brands available on prescription cannot be purchased in the shops. Respondents highlighted that if prescriptions are withdrawn, access to gluten free staples will be more difficult for the elderly, those on low incomes and those relying on public transport that may not go to some of the larger, out of town supermarkets that will stock the greatest range of gluten free products. Exemptions Respondents suggested exemptions for children, elderly people and those on low incomes. Coeliac UK stated that if approved, this proposal would result in health inequality and have a disproportionate impact on the most vulnerable. They suggested guidance should be included for patients and health professionals for prescribing for individuals where there is a need in exceptional circumstances. They have also shared ideas about alternatives to prescribing which other CCGs are piloting. Stakeholders Coeliac UK and the BSNA provided a written response to this proposal.

4 Equality Analysis Checklist Equality Group What evidence has been used for this analysis? What engagement & consultation has been used? Identify positive / negative / no outcomes How are you going to address issues identified? Named Lead & time frame Age Coeliac disease diagnosed prevalence increases with age according to West, Joe, et al. "Incidence and prevalence of celiac disease and dermatitis herpetiformis in the UK over two decades: population-based study." The American journal of gastroenterology (2014): Therefore this will have a negative impact on older people. Negative - elderly and/or people who do not have access to the internet or larger supermarkets which stock a wider range of gluten free products. Negative - under 18 s who rely on parents/guardians to purchase on their behalf. Patients will be signposted to places where gluten free food can be purchased & most community pharmacies have the facility to order for purchase products patients would previously have received on prescription. Patients/parents/guardians will be provided with information as above. Their reliance on others to purchase food on their behalf is no different to requirements for other patient groups with food allergies/intolerances (eg nut allergy) where there is currently no provision on the NHS. TBC depending on GB review. Appropriate lead health professional treating patient. Communications process. Disability Negative - could be an impact on disabled or people who do not have access to the internet and the larger supermarkets which stock a wider range of gluten free products. There may be an issue for people with difficulties reading food labels and people with learning disabilities. NICE guidelines highlight that gluten free products are more expensive and are usually only available from larger retailers, making access more difficult for people on low incomes or with limited mobility. Patients will be signposted to places where gluten free food can be purchased & most community pharmacies have the facility to order for purchase products patients would previously have received on prescription. Where requested we will endeavour to ensure patient information produced is accessible to all patient groups (Accessible Information Standard - AIS).

5 Gender reassignment Marriage & civil partnership Race Kingston is an ethnically diverse borough (26% BME Census) with a large Korean community in New Malden (largest in Europe), language is a significant barrier. There is also a large Tamil speaking community in North Kingston. Negative - could be an impact on people whom English is not their first language and may not therefore be able to identify gluten free options online or in local supermarkets. We will need to consider providing patient information in appropriate languages to ensure accessibility to all patient groups is met. Religion or belief Sex Prevalence of diagnosed coeliac disease is higher in females than males. West, Joe, et al. "Incidence and prevalence of celiac disease and dermatitis herpetiformis in the UK over two decades: population-based study." The American journal of gastroenterology (2014): Negative could affect women more than men as prevalence is at least twice as high in women. Patients will be signposted to places where gluten free food can be purchased & most community pharmacies have the facility to order for purchase products patients would previously have received on prescription. Patients will be signposted to the Coeliac UK website where further resources are available. ions/coeliacdisease/pages/introducti on.aspx

6 Sexual orientation Other: Carers Low incomes Data from the 2015 Indices of Multiple Deprivation demonstrates that there are small pockets of relative deprivation in Kingston. Overall however the borough is generally affluent, and the second least deprived borough in London. In Kingston the Cambridge Road Estate in Norbiton is the most deprived in the borough, and the only LSOA in the 20% most deprived in the country. Other small pockets of relative deprivation exist in Malden Manor (Old Malden), Kingsnympton Estate (Coombe Hill) and York Way/Garrison Lane (Chessington South). Negative - patients on low incomes could be negatively impacted by this change. They may not be easily able to afford gluten free food, which can be more expensive than gluten containing equivalents. There could be additional negative impact if this group are also unable to access online shopping or larger supermarkets, where the choice can be greater and costs lower. NICE guidelines highlight that as coeliac disease can affect more than one member of a family it can also be an additional burden on the family budget. To address this, healthcare professionals should highlight if gluten free food products are available on prescription to help people to maintain a gluten free diet. All patients affected by the change should be given comprehensive information detailing the many naturally gluten free foods that are available to buy at a reasonable cost - for example rice, potatoes, pulses. The gluten free market is increasing in availability, therefore the market has become more competitive and prices are reducing to become more comparable with regular gluten containing products. Patients will be signposted to the Coeliac UK website where further resources are available. Prescribing data currently suggests that the highest rates of prescribing are in areas where levels of deprivation are generally lower. Therefore the impact of withdrawing gluten free prescribing should have a lower impact on the low income patient population.

7 Action Plan Equality Group Prescribing costs data for gluten free food items between January - December 2016 shows that three practices (The Groves Medical Centre, Langley Medical Centre and Orchard Practice) prescribe the most. Whilst there need to be a certain level of assumption in this analysis, with the exception of Orchard, these practices are generally not serving the most deprived parts of the borough. Negative Outcome Mitigating Action (inc resource implications) Named Lead & Timeframe Age The elderly and/or people who may not have access to the internet or larger supermarkets which stock a wider range of gluten free products may find it harder to access gluten free foods which they may previously have received on prescription. Signposting & promoting information will require resources in terms of printed information and general communications. TBC depending on GB review. Appropriate lead health professional treating patient. Communications process. Disability Those who have a disability or people who do not have access to the internet and the larger supermarkets which stock a wider range of gluten free products may find it harder to access gluten free foods which they may previously have received on prescription. Signposting & promoting information will require resources in terms of printed information and general communications, and ensuring it is accessible to all patient groups. Education and support for GPs and community pharmacies in order to provide support for patients. Patient information will be accessible to all

8 patient groups in line with the AIS. Gender reassignment Marriage & Civil Partnership Pregnancy & maternity Race People for whom English is not their first language and may not therefore be able to identify gluten free options online or in local supermarkets may find it harder to access gluten free foods which they may have previously received on prescription. Will need to ensure we have the resources and ability to produce patient information in community languages. Patient information will be accessible to all patient groups in line with the AIS. Religion or belief Sex Could affect women more than men as prevalence is at least twice as high in women. Patients will be signposted to places where gluten free food can be purchased & most community pharmacies have the facility to order for purchase products patients would previously have received on prescription. Patients will be signposted to the Coeliac UK website where further resources are available. Sexual orientation Other - Carers Other - low income People on low incomes may not easily be able to afford gluten free food and so may find it harder to access gluten free foods Signposting & promoting information will require resources in terms of printed information and

9 which they may have previously received on prescription. general communications, and ensuring it is accessible to all patient groups. Education and support for GPs and community pharmacies in order to provide support for patients. 2. Prescriptions for Vitamin D Vitamin D helps to regulate the amount of calcium and phosphate in the body. These nutrients are needed to keep bones, teeth and muscles healthy. A lack of vitamin D can lead to bone deformities such as rickets in children, and bone pain and tenderness as a result of osteomalacia in adults. In 2012, Chief Medical Officers for the UK published a letter to health professionals to increase awareness of the risk of vitamin D deficiency amongst certain groups (including older people, children under 5, people with dark complexions, pregnant women). The letter set out a recommendation for vitamin D supplementation in these risk groups and advised that vitamin D was available for purchase or could be prescribed for those who are not eligible for the Healthy Start scheme. Since publication, some practices have promoted self-care whilst others have prescribed for their patients, creating inequality in their approach. Promoting self-care in all areas will help address this, and is increasingly important since the Scientific Advisory Committee on Nutrition (SACN) published recommendations in July 2016 advising vitamin D supplementation for everyone over 1 year of age, either daily or at least during the autumn/winter months depending on their risk factors. Currently the CCG spends 5,000 on vitamin D every year. What engagement & consultation has been used? The CCG ran Choosing Wisely engagement between 15 March and 14 July 2017 (including a pause for the general election purdah from 20 April 8 June) to gather the views of local people about the proposals. The engagement document asked for feedback on these areas as well as asking if respondents had any concerns about the proposals, whether there should be any specific exemptions and if there were any other comments that should be taken into consideration. Over 200 were received and the survey results relating to Vitamin D show that 73% strongly agreed or agreed and 27% disagreed or strongly disagreed that the local NHS should stop prescribing gluten free foods. There was strong support for this proposal however the main areas of concern if this proposal were to be taken forward are: That potentially a wider use of vitamin D amongst more vulnerable groups (elderly, cancer survivors and those with chronic conditions) would result in greater long term savings for the NHS by improving disease resistance. Whilst vitamin D is widely available in the shops, there would need to be education and information to support patients to ensure people know how much to take and where to purchase it from. Exemptions

10 Suggested the elderly, cancer patients and those with chronic conditions should be exempt from the proposal. Equalities Analysis Checklist Equality Group What evidence has been used for this analysis? What engagement & consultation has been used? Identify positive / negative / no outcomes How are you going to address issues identified? Named Lead & timeframe Age According to the Kingston Data Observatory, the areas of Kingston with the highest number of 0-4 year olds is Canbury ward, followed by Coombe Hill and Chessington South (Census 2011 data). St James, Old Malden and Coombe Hill wards have the greatest numbers of over 65 s, and the GLA population projections expect the population of older people in Kingston borough to increase. Overall the borough has a slightly lower than England average number of older people, but higher than the London average. (2013, Kingston Data Observatory). Negative Older people and children under 5 are groups most at risk of vitamin D deficiency. Kingston has a higher than England average number of young people. People who are aged 65 years and over who may currently have vitamin D prescribed by their GP will also be negatively affected as they will now be redirected to purchase these, when in the past they obtained free supplies on prescription due to their age exemption. All patients affected by the change should be given comprehensive information detailing where they can purchase vitamin D. Promotion of need to purchase over the counter vitamin D supplements in relevant areas Signpost eligible individuals to obtain Healthy Start vitamin supplements. TBC depending on GB review. Appropriate lead health professional treating patient. Communications process Disability

11 Gender reassignment Marriage & Civil Partnership Pregnancy & maternity Kingston has a lower live birth rate per 1,000 population than London and England (54, 64, and 62 per 1000 popn respectively). Negative may impact pregnant women or those who are eligible for maternity prescription charge exemption if they previously received or are currently in receipt of vitamin D supplements on prescription. Race Kingston is an ethnically diverse borough (26% BME Census) with a large Korean community in New Malden (largest in Europe), language is a significant barrier. There is also a large Tamil community in North Kingston. Negative using ethnicity as a marker to identify likelihood of individuals having darker skin and based on the risk factor that people with darker skin are known to have an increased risk of vitamin D deficiency. This proposal may have a negative impact on people of non-white ethnicity groups who currently obtain vitamin D supplements from their GP on prescription and are not eligible for prescription charges. We will need to consider providing patient information in appropriate languages to ensure accessibility to all patient groups is met. Religion or belief Negative people who cover their skin for religious reasons and currently received vitamin D supplements from their GP on prescription, and are not eligible for prescription charges, may be negatively impacted by this proposal. Sex Sexual orientation

12 Other - Carers Other - low income Data from the 2015 Indices of Multiple Deprivation demonstrates that there are small pockets of relative deprivation in Kingston. Overall however the borough is generally affluent, the second least deprived in London. Negative this proposal may negatively affect individuals on low incomes who previously obtained vitamin D supplements on prescription free of charge as they will now be redirected to purchase supplements. In Kingston the Cambridge Road Estate in Norbiton is the most deprived in the borough, and the only LSOA in the 20% most deprived in the country. Other small pockets of relative deprivation exist in Malden Manor (Old Malden), Kingsnympton Estate (Coombe Hill) and York Way/Garrison Lane (Chessington South).

13 Action Plan Equality Group Negative Outcome Mitigating Action (inc resource implications) Named Lead & Timeframe Age People who are aged under 5 or aged 65 and over who may currently have vitamin D prescribed by their GP will be negatively affected as they will now be required to purchase these when in the past they would have obtained free supplies on prescription. All patients affected by the change should be given comprehensive information detailing where they can purchase vitamin D. Promotion of need to purchase over the counter vitamin D supplements in relevant areas TBC depending on GB review. Appropriate lead health professional treating patient. Communications process Signpost eligible individuals to obtain Healthy Start vitamin supplements. Disability Gender reassignment Marriage & Civil Partnership Pregnancy & maternity May negatively impact pregnant women or those who are eligible for maternity prescription charge exemption if they previously received or are currently in receipt of vitamin D supplements on prescriptions. They will now need to purchase them as part of self-care. Race Negative using ethnicity as a marker to identify likelihood of individuals having darker skin and based on the risk factor that people with darker skin are known to have an increased risk of vitamin D deficiency. This proposal may have a negative impact on people of non-white ethnicity groups who currently obtain vitamin D supplements from their GP on prescription and are not eligible for prescription charges.

14 Religion or belief People who cover their skin for religious reasons and currently receive vitamin D supplementation from their GP practice on prescription, and are not eligible for prescription charges, may be negatively impacted by this proposal. Sex Sexual orientation Other - Carers Other - low income This proposal may negatively affect individuals on low incomes who previously obtained vitamin D supplements on prescription free of charge as they will now need to purchase supplements. It is worth noting that only 5,000 worth of vitamin D was prescribed across Kingston (Jan Dec 2016), so the numbers affected by this proposal are low. 3. Prescriptions for baby milk and specialist infant formula Historically it was difficult to buy infant formula used for lactose intolerance as there was a limited range available on the high street. There is now online and in store availability of cow s milk and lactose free alternatives for infant formula at most major pharmacies and supermarkets. In many cases these are now at a similar cost to standard infant formula. We are proposing that infant formula and baby milks will only be prescribed where there is a medical need for example, for babies and infants with conditions including faltering growth, pre-term infants and specific medical conditions such as renal or liver disease and phenylketonuria. Lactose intolerance is a common digestive problem where the body is unable to digest lactose, a type of sugar mainly found in milk and dairy products. In the UK, lactose intolerance is more common in people of Asian or African-Caribbean descent. It can develop at any age, although many cases first develop in people aged 20 to 40, although babies and young children can also be affected. (NHS Choices). In the UK, 5% of the population are thought to suffer any degree of lactose intolerance. (Nutrition.org.uk) There are no local Kingston level statistics available for lactose intolerance prevalence. Currently the CCG spends about 386,000 on baby milk and specialist infant formula every year.

15 What engagement & consultation has been used? The CCG ran Choosing Wisely engagement between 15 March and 14 July 2017 (including a pause for the general election purdah from 20 April 8 June) to gather the views of local people about the proposals. The engagement document asked for feedback on these areas as well as asking if respondents had any concerns about the proposals, whether there should be any specific exemptions and if there were any other comments that should be taken into consideration. Over 200 were received and the survey results relating to baby and infant formula show that 58% strongly agreed or agreed and 42% disagreed or strongly disagreed that the local NHS should stop providing all prescribed soya, thickened or lactose free baby milk and infant formula other than for the exempt groups listed. There was support for the proposal around baby milk and infant formula however the main areas of concern if this proposal were to be taken forward are: Cow s milk protein allergy (CMPA) A number of respondents highlighted concerns that the engagement document was unclear as to whether specialist formula for babies and infants diagnosed with CMPA would be exempted from the proposal. They were very seriously concerned that if it is included this proposal will place infants with CMPA at serious risk of harm. Allergy UK, The Association of UK Dieticians and BSACI expressed concerns regarding this confusion around CMPACMPA is a highly complex food allergy and requires extensively hydrolysed or amino acid formulas which are only available on prescription and not over the counter. If prescribing for hydrolysed or amino acid formulas are removed there is likely to be significant impact on the ability of parents to feed their children in cases where breast milk is not used. The CCG should work in line with Milk Allergy in Primary Care (MAP) Guidelines, BSACI guidelines for CMPA and NICE guidelines. Guidance for GPs to support patients There is a need for greater guidance and support for GPs around diagnosis for allergic conditions including CMPA as other formulas are unlikely to be suitable and may be given for unrecognised CMPA. Greater education and training for GPs in the recognition and management of allergic conditions such as CMPA could lead to a reduction in prescriptions and effective diagnosis of CMPA. The GP/healthcare professional has an important role in supporting parents to ensure that the appropriate formula/milk is prescribed for their child and then used under medical supervision to avoid complications arising for the child and significant distress for the parents. Cost of infant formula and baby milks There was concern from Allergy UK and other respondents about the suggestion that the cost of alternatives are now at a similar cost to standard infant formula. Specialist infant formulas for CMPA are not similar to lactose free formulas and the formulas needed to deal with this allergy are very expensive. One respondent stated the costs as being up to 38 per 400g tin compared to 10 per 800g tin for standard formula.

16 Impact would be felt most by low income families, or mothers who may have a medical condition for whom breast feeding is not possible and therefore alternative formulas are required. Exemptions Babies with swallowing difficulties should be included in the exemptions. Stakeholder views Allergy UK, along with The Association of UK Dieticians and British Society for Allergy & Clinical Immunology (BSACI) provided a written response to this proposal. Equalities Analysis Checklist Equality Group What evidence has been used for this analysis? What engagement & consultation has been used? Identify positive / negative / no outcomes How are you going to address issues identified? Named Lead & timeframe Age The areas of Kingston with the highest number of 0-4 year olds is Canbury ward, followed by Coombe Hill and Chessington South (Census 2011 data). Prescribing data (Jan Dec 2016) shows the highest prescriber in monetary terms is The Groves, followed by Churchill and Canbury. Canbury Medical Practice serves Canbury ward. Negative - it is likely this will impact primarily on infants 0-4 year olds, with a potential knock-on effect for their families. Positive - inappropriate use of specialised infant formula feeds including prolonged use beyond recommended age can have an adverse effect on infants resulting in conditions such as constipation and iron deficiency. Therefore this may in fact have a positive impact where inappropriate prescribing is identified and the infant/child is reviewed and product discontinued. All patients affected by the change should be given comprehensive information detailing where they can purchase specialised infant formula feeds and that most community pharmacies have the facility to order for purchase products patients would previously have received on prescription. TBC depending on GB review. Appropriate lead health professional treating patient. Communicatio ns process Disability Gender

17 reassignment Marriage & Civil Partnership Pregnancy & maternity Race Kingston is an ethnically diverse borough (26% BME Census) with a large Korean community in New Malden (largest in Europe), language is a significant barrier. There is also a large Tamil community in North Kingston. Negative - could be an impact on people whom English is not their first language and may not therefore be able to identify appropriate baby milk and specialist infant formula options online or in local supermarkets. Negative could be a greater negative impact on people of Asian or African Caribbean descent. We will need to consider providing patient information in appropriate languages to ensure accessibility to all patient groups is met. The highest prescribing practice (Jan-Dec 2016) is The Groves, which serves New Malden. In the UK, lactose intolerance is more common in people of Asian or African- Caribbean descent. Religion or belief Sex Sexual orientation

18 Other - Carers Other - low income Data from the 2015 Indices of Multiple Deprivation demonstrates that there are small pockets of relative deprivation in Kingston. Overall however the borough is generally affluent, the second least deprived in London. In Kingston the Cambridge Road Estate in Norbiton is the most deprived in the borough, and the only LSOA in the 20% most deprived in the country. Other small pockets of relative deprivation exist in Malden Manor (Old Malden), Kingsnympton Estate (Coombe Hill) and York Way/Garrison Lane (Chessington South). The Children in Low- Income Families Local Measure shows in Kingston this was 13.8% of children compared with 19.9% the England average (Richmond Child Poverty Negative - There have been concerns that the proposal may disadvantage families from low income households who may not be able to afford the cost of formula feeds. Healthy Start Vouchers might mitigate against this to a certain extent, however, it is recognised that there is a significant shortfall in terms of the monetary value of the voucher ( 3.10 South East CSU figure) and the cost of routine formula milk. These families may be further disadvantaged by having to make the choice to use the voucher for formula rather than fruit or vegetables. It is proposed that those families in receipt of Healthy Start support will be exempt ie that they may spend their vouchers on infant formula milk that is based on cow s milk and says on the packaging it can be used from birth. This therefore includes lactose free milk which is derived from cow s milk. This will need to be communicated to patients and the public to alleviate the concerns, and for prescribers to identify and implement. There is however then the potential for other groups to challenge for consideration as exemption cohorts. From prescribing data Churchill Medical Practice is the second highest prescriber, and is located near the Cambridge Rd and Kingsnympton Estates, areas of relative deprivation. It can be assumed therefore that there might be a negative impact on low income families. However it is also worth considering, in relative terms Kingston is generally an affluent boroughs so the number of families impacted negatively is likely to be small.

19 Strategy 2014). From prescribing data Churchill Medical Practice is the second highest prescriber, and is located near the Cambridge Rd and Kingsnympton Estates. Action Plan Equality Group Negative Outcome Mitigating Action (inc resource implications) Named Lead & Timeframe Age Infants aged 0-4 and potentially a knock on impact to their families who would previously have received baby milk and infant formula on prescription. All patients affected by the change should be given comprehensive information detailing where they can purchase specialised infant formula feeds and that most community pharmacies have the facility to order for purchase products patients would previously have received on prescription. TBC depending on GB review. Appropriate lead health professional treating patient. Communications process Disability Gender reassignment Marriage & Civil Partnership Pregnancy & maternity Race People for whom English is not their first language and may not therefore be able to identify appropriate baby milk and specialist infant formula options online or in local supermarkets. Will need to ensure we have the resources and ability to produce patient information in community languages. Religion or belief

20 Sex Sexual orientation Other - Carers Other - low income There have been concerns that the proposal may disadvantage families from low income households who may not be able to afford the cost of formula feeds. Healthy Start Vouchers might mitigate against this to a certain extent, however, it is recognised that there is a significant shortfall in terms of the monetary value of the voucher ( 3.10 South East CSU figure) and the cost of routine formula milk. These families may be further disadvantaged by having to make the choice to use the voucher for formula rather than fruit or vegetables. It is proposed that those families in receipt of Healthy Start support will be exempt ie that they may spend their vouchers on infant formula milk that is based on cow s milk and says on the packaging it can be used from birth. This therefore includes lactose free milk which is derived from cow s milk. This will need to be communicated to patients and the public to alleviate the concerns, and for prescribers to identify and implement. It is also worth considering, in relative terms Kingston is generally an affluent boroughs so the number of families impacted negatively is likely to be small. 4. Prescriptions for Self-care medications Most minor illnesses will get better within a short period of time. Many people buy medicines from pharmacists and shops to help with their and their family s symptoms. These treatments have no significant effect on the duration of the illness. The majority of people can and do treat themselves without needing to see a GP. The proposal is that in line with the majority of people, where people attend their practice for such self-limiting illnesses, the GP will not prescribe but will ask the patient to buy from their pharmacist or from other sources any medicines they choose to help with their symptoms. This will include for example common painkillers, cough medicines and lozenges for cold and flu symptoms. All patients will continue to be treated with appropriate medication where there is evidence of effectiveness and where their condition requires it. NHS prescribed paracetamol for 16 tablets costs 37p plus an additional NHS dispensing charge; generic paracetamol costs 49p or less and branded paracetamol (eg Panadol) costs The proposed saving to Kingston CCG would be up to 100,000 a year. What engagement & consultation has been used?

21 The CCG ran Choosing Wisely engagement between 15 March and 14 July 2017 (including a pause for the general election purdah from 20 April 8 June) to gather the views of local people about the proposals. The engagement document asked for feedback on these areas as well as asking if respondents had any concerns about the proposals, whether there should be any specific exemptions and if there were any other comments that should be taken into consideration. Over 200 were received and the survey results relating to over the counter medicines show that 84% strongly agreed or agreed and 16% disagreed or strongly disagreed that the local NHS should stop prescribing over the counter medicines for minor illnesses other than for the exempt groups listed. There was very strong support for this proposal however the main areas of concern if this proposal were to be taken forward are: Issue raised in relation to people living in supported accommodation. Staff can only provide prescribed medicines, including painkillers. If the proposal is implemented, policies within both NHS and private supported accommodation would need to be changed. This also applies to children needing medication during school hours where some schools will only allow medicines with a prescription label. At the Refugee/Asylum Seeker Health Day in July organised by Kingston Refugee Action and attended by the CCG, it was noticeable that the majority of those who participated in the engagement receive over the counter medicines on prescription. They were very concerned at the proposal to stop free prescribing, and this would prove a significant cost implication for this particular vulnerable group. Equalities Analysis Checklist Equality Group What evidence has been used for this analysis? What engagement & consultation has been used? Identify positive / negative / no outcomes How are you going to address issues identified? Named Lead & timeframe Age Negative there may be a negative impact on the needs of children and potentially elderly patients requiring these medicines will have to be met by the responsible adult/carer caring for them. Raise awareness amongst the public and target specific age groups eg Staywell, Kingston Carers Network, parent & toddler groups. TBC depending on GB review. Appropriate lead health professional treating patient. Communications process Provide patients/carers with best-buy choices and supporting information through GPs Disability Negative some people with disabilities Raise awareness

22 (such as learning difficulties) may require assistance if they are unable to purchase the right choices independently. The needs of people with disabilities requiring these medicines may need to be met by the responsible carer for them. amongst the public and target specific age groups eg Kingston Carers Network, disability forums etc. Provide patients/carers with best-buy choices and supporting information through GPs Gender reassignment Marriage & Civil Partnership Pregnancy & maternity no evidence / reports to suggest negative impact Race, although will need to ensure patient information and support around any changes to prescribing is in appropriate languages and access to an interpreter if needed to ensure accessibility for all patient groups is met (AIS). Religion or belief Sex Sexual orientation Other - Carers May impact as set out in age/disability. Carers would need to be made aware of decisions made with regards to availability of these self-care products through the NHS, where they are responsible for an individual who may currently be in receipt of self-care

23 medications on prescription. Other - low income Data from the 2015 Indices of Multiple Deprivation demonstrates that there are small pockets of relative deprivation in Kingston. Overall however the borough is generally affluent, the second least deprived in London. In Kingston the Cambridge Road Estate in Norbiton is the most deprived in the borough, and the only LSOA in the 20% most deprived in the country. Other small pockets of relative deprivation exist in Malden Manor (Old Malden), Kingsnympton Estate (Coombe Hill) and York Way/Garrison Lane (Chessington South). Negative this proposal may negatively affect individuals on low incomes who previously obtained self-care medications on prescription free of charge as they will now be redirected to purchase these over the counter. Positive - For those who pay for their prescriptions, medications purchased over the counter are usually cheaper than a prescription and can be purchased without seeing a GP. Raise awareness amongst the public and target specific age groups eg Kingston Carers Network, disability forums etc. Provide patients/carers with best-buy choices and supporting information through GPs Due to the very low unit costs of these products it is not anticipated this will impact very negatively on health inequalities, particularly as there are not widespread areas of deprivation in Kingston. There is no clear pattern in local Kingston prescribing data that would demonstrate a link between low income and GP surgeries prescribing rates.

24 Action Plan Equality Group Negative Outcome Mitigating Action (inc resource implications) Named Lead & Timeframe Age May negatively impact on the needs of children and potentially elderly patients requiring these medicines will have to be met by the responsible adult/carer caring for them. Raise awareness amongst the public and target specific age groups eg Staywell, Kingston Carers Network, parent & toddler groups. Provide patients/carers with best-buy choices and supporting information through GPs TBC depending on GB review. Appropriate lead health professional treating patient. Communications process Disability May negatively impact some people with disabilities (such as learning difficulties) who may require assistance if they are unable to purchase the right choices independently. The needs of people with disabilities requiring these medicines may need to be met by the responsible carer for them. Raise awareness amongst the public and target specific age groups eg Kingston Carers Network, disability forums etc. Provide patients/carers with best-buy choices and supporting information through GPs Gender reassignment Marriage & Civil Partnership Pregnancy & maternity Race Religion or belief Sex Sexual orientation Other - Carers May be a negative impact as set out in Carers would need to be made aware of decisions

25 age/disability. made with regards to availability of these self-care products through the NHS, where they are responsible for an individual who may currently be in receipt of self-care medications on prescription. Raise awareness amongst the public and target specific groups as relevant. Provide patients/carers with best-buy choices and supporting information through GPs Other - low income May negatively affect individuals on low incomes who previously obtained self-care medications on prescription free of charge as they will now be redirected to purchase these over the counter. Raise awareness amongst the public and target specific relevant groups. Provide patients/carers with best-buy choices and supporting information through GPs Due to the very low unit costs of these products it is not anticipated this will impact very negatively on health inequalities. 5. IVF and specialised fertility services Infertility is defined as the failure to fall pregnant after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology (where no reason can be found). The success rate of IVF depends on the age of the woman undergoing the treatment as well as the cause of the infertility, if it is known. Younger women are more likely to have healthier eggs, which increases the chances of success. In 2014 the CCG revised its IVF policy to: Increase the age for women up to their 43rd birthday to meet the National Institute for Health and Care Excellence (NICE) recommendation Make fertility investigations available to same-sex couples, provided they are able to demonstrate sub-fertility Routinely fund the following treatments: o Cryopreservation and storage pre-cancer treatment o Intra-uterine insemination o Donor insemination o Ovulation Induction o Surgical Sperm retrieval

26 The CCG is now considering whether to significantly increase the thresholds for IVF and specialised fertility services which could mean: IVF and specialised fertility treatment is available only for people with infertility as a result of cancer treatment or to prevent transmission of chronic viral infections; or IVF and specialised fertility treatment is no longer commissioned. Kingston CCG s annual spend on IVF and specialised fertility services is estimated to be 360,000. If the CCG goes ahead and changes the access criteria or no longer commissions IVF and specialised fertility services, the number of people in the borough likely to be affected is low. Each year around 100 people in the Kingston CCG area undergo NHS funded IVF treatment. What engagement & consultation has been used? The CCG ran Choosing Wisely engagement between 15 March and 14 July 2017 (including a pause for the general election purdah from 20 April 8 June) to gather the views of local people about the proposals. The engagement document asked for feedback on these areas as well as asking if respondents had any concerns about the proposals, whether there should be any specific exemptions and if there were any other comments that should be taken into consideration. Over 200 were received and the survey results relating to IVF and specialised fertility services show that 52% strongly agreed or agreed and 48% disagreed or strongly disagreed that the local NHS should only make IVF available in exceptional circumstances. There was support for the proposal around IVF and specialised fertility services but the results were very close. The main areas of concern if this proposal were to be taken forward are: Departing from NICE guidelines and postcode lottery Respondents commented that the proposals are not in line with NICE guidance and will increase the postcode lottery facing people locally who may need to access fertility services. Many respondents said the current position should be maintained and that in fact the current limitation of funding 1 cycle does not meet the NICE guidelines. Some respondents suggested at least 2 cycles should be funded. Long term costs associated with reducing IVF treatment Respondents pointed out there could be long term costs associated with reducing access to fertility treatment including an increase in people presenting to their GPs with depression, anxiety and other associated conditions and are thus more expensive to the system. In recent years fertility treatment abroad has become an increasingly affordable option for UK patients unable to access IVF on the NHS. Whilst it may be a more affordable option for patients, it can carry hidden costs for the NHS. The Human Fertilisation & Embryology Authority (HFEA) strictly regulates the number of embryos that can be transferred during IVF treatment in the UK to reduce the chance of multiple pregnancies because of the complications for mothers and babies and high costs that arise out of multiple pregnancies. In Europe IVF cycles are much more likely to conduct two or more embryo transfers. By reducing access to NHS IVF,

27 this will increase the risk that these patients may seek treatment abroad which could drive up the number of multiple births locally. There is currently no data available about the number of local births as a result of going abroad for IVF treatment. Mental health impact Though it affects a small percentage of the population, infertility has a significant impact on this group. Individuals dealing with the consequences of infertility such as depression, anxiety, impact on relationships and working life and other associated conditions will have their mental health impacted further by not being able to access NHS funded treatment. Fertility Fairness stated patients dealing with infertility often struggle to hold down jobs and face an increased rate of marriage breakdown. Low income groups A number of respondents highlighted the disproportionate impact on low income groups unable to self-fund IVF treatment thus effectively denying them the opportunity; giving rise to the resulting questions of equality and health inequalities within the population. Exemptions Concerns were raised by Fertility Fairness that infertility is a disease recognised by the World Health Organisation and therefore as with any other medical condition is deserving of treatment and that there shouldn t be specific exemptions. Some respondents said they disagreed with the proposal to reduce access to IVF treatment but did suggest there may be grounds for reviewing the upper age limit, and basing access on likely success rates based on clinical tests. Some respondents said that single women and female couples should be given the same consideration as male-female couples. Note the current Kingston CCG policy applies to couples that include a female partner capable of carrying a pregnancy to term. Sub-fertility will be funded for women in same sex couples if those seeking treatment are demonstrably sub fertile. Stakeholder views Fertility Fairness provided a written response to this proposal. Prevalence of IVF service use in equality groups/protected characteristics The details below show the breakdown of users of IVF/ICSI services in Kingston over the last 2 years (2015/16 and 16/17 to date) by age and ethnicity, compared for ethnicity to the Kingston borough profile.