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1 (Risk level will be added by EQIA steering group) 3. Rapid Impact Assessment summary report Each of the numbered sections below must be completed Interim report Final report x (Tick as appropriate) 1. Title of plan, policy or strategy being assessed. A Dynamic Quality Improvement framework for the management of Vulnerable Patients (Adults) in Hospitals across Lothian 2. What will change as a result of this proposal? Build future requirements for both inpatients, out patient and community settings. 3. Briefly describe public involvement in this proposal No direct involvement with public members in the development of the action plan, however members of the public/lay personnel will be involved in, at minimum, three of the sub-groups, discharge planning, volunteering and carer support. 4. Date of RIA 6 th December 2012 Audit Risk Level: Medium 5. Who was present at the RIA? Identify facilitator and any partnership representative present Name Job Title Date of RIA training Carol Crowther James Glover (Facilitator) Alison Jarvis Tracy Ryan Neil Muir Chief Nurse Head of Equality and Diversity Project Manager - Review of Nursing in the Community Consultant Clinical policy Advisor Nov 2008

2 6. Evidence available at the time of the RIA Evidence Available? Comments: what does the evidence tell you? Data on populations in need Yes NHSL possesses significant data in terms of the number of patients over 65 years of age with a diagnosis of dementia, these will be one of the specific groups this action plan will support. Also data on patients with a learning disability. Data on service uptake/access Yes patient movement within NHSL is available and can be called upon in relation to specific actions within the plan, in particular there will be an interest in patient movement and this is an area that requires further development. Data on quality/outcomes Minimal Some data will be pulled from complaints and incident reporting. Research/literature evidence Yes Significant literature review undertaken for the 5x5x5 improving patient experience for vulnerable adults. Patient experience information Consultation and involvement findings Minimal No Some anecdotal, some from patient experience picked up on through the Older People in Acute Care methodology HIS Inspection. But will be included once draft passes through relevant groups (as referred to above). Good practice guidelines Yes NHS Dementia Standards and Standards for Older People 2004 Other (please specify) 7. Population groups considered Older people, children and young people Women, men and transgender people (include issues relating to pregnancy and maternity) Potential differential impacts The framework is for adults only and not children. It is clear that staff must not focus wholly on older patients but must focus on all vulnerable adults. However as older patients make up a significant part of our inpatients this will have a greater effect. This framework, at present, relates to in-patients only but will expand to include out-patients/primary care facilities in the future. There is a greater amount of older women in the population than men, but different services will have different clinical needs. For example there are more men with Traumatic/acquired brain injuries and men are more likely to abuse substances, e.g.

3 Disabled people (includes physical disability, learning disability, sensory impairment, long term medical conditions, mental health problems) Minority ethnic people (includes Gypsy/Travellers, non-english speakers) Refugees & asylum seekers People with different religions or beliefs Lesbian, gay, bisexual and heterosexual people People who are unmarried, married or in a civil partnership alcohol. Men are also less likely to engage with services. Maternity services are going to see women only, and provision is available for pregnant women who have learning difficulties. Transgender patients may have increased mental health needs however this group of patients is significantly small. This patient grouping, are the main focus of the framework and therefore this framework will have a positive impact on them. However, patients who have sensory impairment may score low on cognitive tests due to their physical rather than their cognitive ability. Communication is always important when interacting with this group. They may present late due to cultural differences and discharge planning should always include family members. Patients who have a cognitive impairment may revert to their original language and any learned languages may be lost, staff should be aware of this. It is possible that this group of individuals may seek healthcare and the framework will allow a positive approach. Staff should respect individual beliefs and treat all patients with dignity especially when dealing with an end of life situation. Person centred care is paramount. Older men may feel a stigma towards their sexual orientation due to their previous experiences, staff should be aware of this and also patients with learning difficulties may have varied sexual preferences and staff should afford them the same respect as they would any other patient. There may be an increased chance of patients who are unmarried living alone and having a reduced support network. Patient that are married or in a civil partnership may be at more risk of becoming financially abused and staff should be aware of this.

4 People living in poverty / people of low income Homeless people People involved in the criminal justice system People with low literacy/numeracy People in remote, rural and/or island locations Carers (including parents, especially lone parents; and elderly carers) Staff (including people with different work patterns e.g. part/full time, short term, job share, seasonal) OTHERS (PLEASE ADD): Patients who have suffered sexual abuse This is an increasing user group and discharge planning will be hugely important for the planning of related services. The framework should have a positive effect. Staff should not impose their own personal beliefs on this group, and treat people s lifestyle choices with dignity and respect. NHS Lothian is now responsible for the delivery of healthcare in prisons and staff should treat all patients with dignity and respect. ¼ of all adults in Lothian have literacy problems. Use of other tools, for example pictorial aids, is to be considered. This may be affected by the council policy in the area the patient lives. Discharge should be considered when the patient is first admitted and the planned admission time should be sympathetic to those that live in rural areas. It may be difficult to get in for a 0730 appointment time if you have some distance to travel. Carers should be included throughout and treated as equal partners. Staff should also be aware of the need to see certain documents, e.g. power of attorney. There may also be difficulty when the vulnerable adult is also the carer, staff may have to consider the use of emergency respite care in these circumstances. The framework may be seen to increase workload and there will be additional training required. Support is available. Patients who fall under this category may be those who have been abused and those who have been abusers. These individuals may as they become older become cognitively impaired and consideration will need to be made as to how we keep these patients safe and how we protect those on the sex offenders register. 8. What positive impacts were identified and which groups will they affect? Impacts Affected populations Equality

5 Diet and Nutrition Education, Learning and Skills Social Environment Living Conditions Accidental Injuries or Public Safety Health Care Social Services Education Staff 9. What negative impacts were identified and which groups will they affect? Impacts Affected populations Nothing to note 10. What communications needs were identified? How will they be addressed? There will be a need for the key stakeholders on the Vulnerable Peoples Steering Group to ensure that the actions required within this framework are properly and appropriately communicated to all staff to ensure that benefits are obvious. 11. Additional Information and Evidence Required N/A 12. Recommendations This is a dynamic evolving document based on a number of existing local and national policies and procedures. Many of the bi-products of the framework may well, in the future require to under go; a RIA in their own rights, i.e. further work on discharge planning, environmental dementia standards etc. Future development of TRAK with patients with additional needs may require further input to this dynamic framework as it progresses. There are some specific issues that require to be considered, in particular in relation to patient s ethnicity relating to discharge planning. Religion and sexual orientation should be picked up through compassionate care work. There are some issues in relation to Consent and Capacity/Power of Attorney in relation to patient admissions and also in relation to security of patients in certain areas of NHS Lothian and consideration needs to be given to the Human Rights aspect of this. 13. Specific to this RIA only, what actions have been, or will be, undertaken and by when? Please complete: Specific actions (as a result of the RIA) Who will take them forward (name and contact details) Deadline for progressing Review date A number of areas within the framework require to have some reinforcement in terms of communication of actions. These aspects will be taken forward by the workstream leads. These will be progressed at the April 2013

6 These are specifically in relation to discharge planning, pre-admission procedures, patients who may have low literacy, patients who may not have English as a first language or may revert to their native tongue when confused and carer assessment. January / February meeting of the Vulnerable Patients Steering Group 14. How will you monitor how this policy, plan or strategy affects different groups, including people with protected characteristics? This dynamic action plan will be progressively reviewed at each of the steering group meetings and will report back to Healthcare Governance & Risk Management of NHS Lothian at their March/April meeting and thereafter 6 monthly. Manager s Name: Carol Crowther, Chief Nurse Quality & Professional Standards Date: 17 December 2012 Please send a completed copy of the summary report to: James Glover, Head of Equality and Diversity Note that you will be contacted by a member of NHS Lothian s impact assessment group for quality control and/or monitoring purposes.

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