HOSPITAL POLICY - Policy for the prevention of venous thromboembolism (VTE) in adult and teenage
Equality & Health Impact Assessment for
Policy for the prevention of venous thromboembolism (VTE) in adult and teenage inpatients
Please read the Guidance Notes in Appendix 1 prior to commencing this Assessment
Please note:
- The completed Equality & Health Impact Assessment (EHIA) must be
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- Included as an appendix with the cover report when the strategy, policy, plan, procedure and/or service change is submitted for approval
- Published on the UHB intranet and internet pages as part of the consultation (if applicable) and once agreed. Formal consultation must be undertaken, as required[1]
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- Appendices 1-3 must be deleted prior to submission for approval.
Please answer all questions:-
1. |
For service change, provide the title of the Project Outline Document or Business Case and Reference Number
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Policy for the prevention of venous thromboembolism (VTE) in adult and teenage inpatients Reference Number – UHB 106 Version 3 (previous reference number 362) |
2. |
Name of Clinical Board / Corporate Directorate and title of lead member of staff, including contact details
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Haematology Directorate/Specialist Services Marilyn Rees Lead VTE CNS Marilyn.Rees2@wales.nhs.uk
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3. |
Objectives of strategy/ policy/ plan/ procedure/ service
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To ensure the Health Board delivers its aims, objectives, responsibilities and legal requirements transparently and consistently, it is the policy of Cardiff and Vale University Health Board (UHB) to follow the guidance as set out in the NICE NG89 and those measures required by the Welsh Assembly Government (WAG):
The objectives of this policy and associated procedure are to provide a rational and practical framework on which to maximise patient safety during and following their hospital stay minimising their risk of developing hospital associated thrombosis |
4. |
Evidence and background information considered. For example
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Cardiff & Vale University Local Health Board (LHB) area is the smallest and most densely populated LHB area in Wales, primarily due to Wales’ capital city: Cardiff. 72.1 and 27.9 percent of the LHB area population live within Cardiff and the more rural Vale of Glamorgan respectively
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Population pyramids are available from Public Health Wales Observatory[2] and the UHB’s ‘Shaping Our Future Wellbeing’ Strategy provides an overview of health need[3].
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The policy details the assessment and management of VTE in the adult patient. The assessment ensures that all patients are individually assessed for their risk of VTE, risk of bleeding and appropriate clinical intervention/management is delivered.
Each year, one in every 1,000 people in the UK is affected by DVT. Anyone can develop it but it becomes more common with age. As well as age, risk factors include:
VTE assessment provides a standardised approach that will help identify those with differential health outcomes and lead to positive action where required. There may potentially be an impact on patients understanding of information and use of a clear concise risk assessment utilising an appropriate educational approach for the patient or carers requirements should be utilised.
Google search for Thromboprophylaxis Policy /Thromboprophylaxis Policy Equality / In-patient thromboprophylaxis equality impact assessment accessed 24th October 2020
1. Thromboprophylaxis Policy and Guidelines – Sherwood Forest Hospitals 2016 |
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Comparison made with these policies of equality impact taking into account age, race, disability, gender, sexual orientation, religion or cultural beliefs. All policies accessed support the content of this policy and the approach recommended to patient groups and risk assessment for venous thromboembolism.
Welsh Government supports and is committed to reducing the incidence of hospital acquired thrombosis and this is described in the Quality Delivery Plan (QDP) for the NHS: Achieving Excellence generating a tier 1 approach and focus. 2012.
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5. |
Who will be affected by the strategy/ policy/ plan/ procedure/ service
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Population Group – All adult patients and teenagers from 13yrs and over admitted to Cardiff and Vale UHB. There are no foreseen specific language/religious /cultural issues.
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- EQIA / How will the strategy, policy, plan, procedure and/or service impact on people?
Questions in this section relate to the impact on people on the basis of their 'protected characteristics'. Specific alignment with the 7 goals of the Well-being of Future Generations (Wales) Act 2015 is included against the relevant sections.
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
6.1 Age For most purposes, the main categories are:
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This policy applies to all adults over the age of 16. Regardless of their age, uniform assessment will be undertaken, which is free from bias or discrimination according to protected characteristics. Where an age is considered to be an individual risk factor, this is considered within the context of the whole risk assessment process, which is based on national guidance
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Not applicable |
Not applicable |
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
6.2 Persons with a disability as defined in the Equality Act 2010 Those with physical impairments, learning disability, sensory loss or impairment, mental health conditions, long-term medical conditions such as diabetes
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This policy applies to all adults over the age of 16. Regardless of whether they have cancer or any other disability, uniform assessment will be undertaken, which is free from bias or discrimination according to protected characteristics. Where cancer, or any other disability eg long term condition is considered to be an individual risk factor, this is considered within the context of the whole risk assessment process, which is based on national guidance
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How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
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6.3 People of different genders: Consider men, women, people undergoing gender reassignment
NB Gender-reassignment is anyone who proposes to, starts, is going through or who has completed a process to change his or her gender with or without going through any medical procedures. Sometimes referred to as Trans or Transgender
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This policy applies to all adults over the age of 16. Regardless of their gender, uniform assessment will be undertaken, which is free from bias or discrimination according to protected characteristics. Where the use of hormonal therapy for gender reassignment is considered to be an individual risk factor, this is considered within the context of the whole risk assessment process, which is based on national guidance
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How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
6.4 People who are married or who have a civil partner.
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There appears not to be any impact. No documented evidence found from the assessment review of the information available |
Not applicable |
Not applicable |
6.5 Women who are expecting a baby, who are on a break from work after having a baby, or who are breastfeeding. They are protected for 26 weeks after having a baby whether or not they are on maternity leave.
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There is specific guidance within the Obstetric Directorate for assessment and management of risk in patients during pregnancy and following birth for those patients found to require thromboprophylaxis |
Not applicable |
Not applicable |
6.6 People of a different race, nationality, colour, culture or ethnic origin including non-English speakers, |
There appears not to be any impact regarding race, nationality, colour, culture or ethnic origin. No documented evidence found |
Would need to ensure patient information leaflets were accessible to patients requiring them. |
This would be provided by the relevant clinical teams |
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
gypsies/travellers, migrant workers
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from the assessment review of the information. Patients whose first language is not English may require written information in the language of their choice to enable understanding of the need for thromboprophylaxis |
These can be accessed from thrombosis.org |
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6.7 People with a religion or belief or with no religion or belief. The term ‘religion’ includes a religious or philosophical belief
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There is a need to be aware that heparins are of animal origin and this may be of concern to some patients. Discuss the alternatives with patients who have concerns about using animal products, after discussing their suitability, advantages and disadvantages with the person. |
Not applicable |
This would be done by the relevant clinical teams |
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
6.8 People who are attracted to other people of:
(heterosexual);
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There appears not to be any impact on staff or patients
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Not applicable |
Not applicable |
6.9 People who communicate using the Welsh language in terms of correspondence, information leaflets, or service plans and design
Well-being Goal – A Wales of vibrant culture and thriving Welsh language
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Bilingually patient information leaflets will be available for patients. This is in line with our current Welsh Language Standards.
The aim of the ‘active offer’ is that staff should ask for the language choice (of either Welsh or English) of the patient. The language choice should then be |
The policy will prompt staff to ask patients which language the patient/service users would like to communicate |
This will need to be done by the relevant clinical teams |
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
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integrated into the patients’ treatment. In other words the patient could request their treatment be in Welsh. If we are unable to provide a fluent Welsh speaker to consult with the person then an interpreter would be provided through video consulting services. |
in, either English or Welsh, in line with the ‘Active Offer’ requirements of the Welsh Governments’ More than Just Words Strategy. |
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6.10 People according to their income related group: Consider people on low income, economically inactive, unemployed/workless, people who are unable to work due to ill-health
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There appears not to be any impact |
Not applicable |
Not applicable |
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
6.11 People according to where they live: Consider people living in areas known to exhibit poor economic and/or health indicators, people unable to access services and facilities
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There appears not to be any impact on staff, and this policy has a positive impact on people on low income as the policy is applicable to all people. All patients admitted to hospital risk of thrombosis according to clinical presentation and following risk assessment tools for their particular speciality |
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6.12 Consider any other groups and risk factors relevant to this strategy, policy, plan, procedure and/or service
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Other groups to be considered would include carers/family members who may need education with regards administering thromboprophylaxis for those requiring extended thromboprophylaxis. It would |
Patient/family member/carer education prior to discharge as well as patient information leaflets to support understanding following discharge into the community |
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How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts |
Recommendations for improvement/ mitigation
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Action taken by Clinical Board / Corporate Directorate. Make reference to where the mitigation is included in the document, as appropriate |
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also be important for those family members/carers as well the patient to understand symptoms suggestive of development of thrombosis following discharge from hospital as the risk remains in place for up to 90 days.
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- HIA / How will the strategy, policy, plan, procedure and/or service impact on the health and well-being of our population and help address inequalities in health?
Questions in this section relate to the impact on the overall health of individual people and on the impact on our population. Specific alignment with the 7 goals of the Well-being of Future Generations (Wales) Act 2015 is included against the relevant sections.
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts and any particular groups affected |
Recommendations for improvement/ mitigation |
Action taken by Clinical Board / Corporate Directorate Make reference to where the mitigation is included in the document, as appropriate |
7.1 People being able to access the service offered: Consider access for those living in areas of deprivation and/or those experiencing health inequalities
Well-being Goal - A more equal Wales
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Access to risk assessment for thromboprophylaxis is not affected by living conditions. On discharge these patients may require additional support to ensure the extended thromboprophylaxis treatment plan is enabled |
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7.2 People being able to improve /maintain healthy lifestyles: Consider the impact on healthy lifestyles, including healthy eating, being active, no smoking /smoking cessation, reducing the harm caused by alcohol and /or non-prescribed drugs plus access to services that support disease prevention (eg immunisation and |
As a policy, there will be no impact. As thrombosis risk increases in patients with higher BMI it is imperative to encourage and support patients in healthy living/eating strategies and make services known to them as per the ‘healthier Wales’ goal by sign posting to available services. General advice would also include reducing alcohol |
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This will need to be actioned by each clinical board |
How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts and any particular groups affected |
Recommendations for improvement/ mitigation |
Action taken by Clinical Board / Corporate Directorate Make reference to where the mitigation is included in the document, as appropriate |
vaccination, falls prevention). Also consider impact on access to supportive services including smoking cessation services, weight management services etc
Well-being Goal – A healthier Wales
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intake to within national guidelines and reduce or stop smoking utilising smoking cessation services for example |
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7.3 People in terms of their income and employment status: Consider the impact on the availability and accessibility of work, paid/ unpaid employment, wage levels, job security, working conditions
Well-being Goal – A prosperous Wales |
As a policy, there will be no impact. |
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How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts and any particular groups affected |
Recommendations for improvement/ mitigation |
Action taken by Clinical Board / Corporate Directorate Make reference to where the mitigation is included in the document, as appropriate |
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7.4 People in terms of their use of the physical environment: Consider the impact on the availability and accessibility of transport, healthy food, leisure activities, green spaces; of the design of the built environment on the physical and mental health of patients, staff and visitors; on air quality, exposure to pollutants; safety of neighbourhoods, exposure to crime; road safety and preventing injuries/accidents; quality and safety of play areas and open spaces
Well-being Goal – A resilient Wales |
As a policy, there will be no impact. |
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How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts and any particular groups affected |
Recommendations for improvement/ mitigation |
Action taken by Clinical Board / Corporate Directorate Make reference to where the mitigation is included in the document, as appropriate |
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7.5 People in terms of social and community influences on their health: Consider the impact on family organisation and roles; social support and social networks; neighbourliness and sense of belonging; social isolation; peer pressure; community identity; cultural and spiritual ethos
Well-being Goal – A Wales of cohesive communities
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As a policy, there will be no impact. |
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7.6 People in terms of macro-economic, environmental and |
As a policy, there will be no impact. |
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How will the strategy, policy, plan, procedure and/or service impact on:- |
Potential positive and/or negative impacts and any particular groups affected |
Recommendations for improvement/ mitigation |
Action taken by Clinical Board / Corporate Directorate Make reference to where the mitigation is included in the document, as appropriate |
sustainability factors: Consider the impact of government policies; gross domestic product; economic development; biological diversity; climate
Well-being Goal – A globally responsible Wales |
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Please answer question 8.1 following the completion of the EHIA and complete the action plan
Approved By: QSE |
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8.1 Please summarise the potential positive and/or negative impacts of the strategy, policy, plan or service |
On reviewing the previous policy and writing the latest version, overall, there appears to be very limited impact on the protected characteristics and health inequalities as a result of this policy. |
Action Plan for Mitigation / Improvement and Implementation
Reference Number: UHB 106 |
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Next Review Date: 13 Apr 2024 |
Version Number: |
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Date of Publication: 15 Apr 2021 |
Approved By: QSE |
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Action |
Lead |
Timescale
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Action taken by Clinical Board / Corporate Directorate |
8.2 What are the key actions identified as a result of completing the EHIA?
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On reviewing the previous policy and writing the latest version, overall, there appears to be very limited impact on the protected characteristics and health inequalities as a result of this policy. There is a need to ensure risk assessments are available for each clinical board to ensure appropriate risk is assessed and treatment prescribed as required There is a need to ensure patient information leaflets are available during their hospital stay and following discharge to risk of reduce hospital acquired thrombosis |
M Rees |
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Action |
Lead |
Timescale
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Action taken by Clinical Board / Corporate Directorate |
8.3 Is a more comprehensive Equalities Impact Assessment or Health Impact Assessment required?
This means thinking about relevance and proportionality to the Equality Act and asking: is the impact significant enough that a more formal and full consultation is required?
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As there has been potentiall very limited negative impact identified, it is unnecessary t undertake a more detailed assessment |
yM Rees
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Action |
Lead |
Timescale
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Action taken by Clinical Board / Corporate Directorate |
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8.4 What are the next steps?
Some suggestions:-
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On reviewing this policy minor positive changes will need to been made. The EHIA has been consulted.
It has been approved by……….. The EHIA will be placed on intranet once approved Adherence to the policy will be monitored through ………………….
The UHB standard is that all policies are reviewed within 3 years (1 year if a statutory requirement).
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Appendix 2 – The Human Rights Act 1998[4]
The Act sets out our human rights in a series of ‘Articles’. Each Article deals with a different right. These are all taken from the European Convention on Human Rights and are commonly known as ‘the Convention Rights’:
- Article 2 Right to life. NHS examples: the protection and promotion of the safety and welfare of patients and staff
- Article 3 Freedom from torture and inhuman or degrading treatment. NHS examples: issues of dignity and privacy, the protection and promotion of the safety and welfare of patients and staff, the treatment of vulnerable groups or groups that may experience social exclusion, for example, gypsies and travellers, issues of patient restraint and control
- Article 4 Freedom from slavery and forced labour
- Article 5 Right to liberty and security. NHS examples: issues of patient choice, control, empowerment and independence, issues of patient restraint and control
- Article 6 Right to a fair trial
- Article 7 No punishment without law
- Article 8 Respect for your private and family life, home and correspondence. NHS examples: issues of dignity and privacy, the protection and promotion of the safety and welfare of patients and staff, the treatment of vulnerable groups or groups that may experience social exclusion, for example, gypsies and travellers, the right of a patient or employee to enjoy their family and/or private life
- Article 9 Freedom of thought, belief and religion. NHS examples: the protection and promotion of the safety and welfare of patients and staff, the treatment of vulnerable groups or groups that may experience social exclusion, for example, gypsies and travellers
- Article 10 Freedom of expression. NHS examples: the right to hold and express opinions and to receive and impart information and ideas to others, procedures around whistle-blowing when informing on improper practices of employers where it is a protected disclosure
- Article 11 Freedom of assembly and association
- Article 12 Right to marry and start a family
- Article 14 Protection from discrimination in respect of these rights and freedoms. NHS examples: refusal of medical treatment to an older person
- solely because of their age, patients presented with health options without the use of an interpreter to meet need, discrimination against UHB staff on the basis of their caring responsibilities at home
Document Title: EHIA VTE in adults and teenage patients |
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Reference Number: UHB 106 |
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Version Number: |
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Approved By: QSE |
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- Protocol 1, Article 1 Right to peaceful enjoyment of your property
- Protocol 1, Article 2 Right to education
- Protocol 1, Article 3 Right to participate in free elections
- Protocol 13, Article 1 Abolition of the death penalty
Document Title: EHIA VTE in adults and teenage patients |
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Reference Number: UHB 106 |
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Version Number: |
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Approved By: QSE |
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Appendix 3
Tips
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Be clear about the policy or decision’s rationale, objectives, delivery method and stakeholders. |
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Work through the Toolkit early in the design and development stages and make use of it as the work progresses to inform you of those most affected and inform mitigating actions |
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Allow adequate time to complete the Equality Health Impact Assessment
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Identify what data you already have and what are the gaps.
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Engage with stakeholders and those most affected early. View them as active partners rather than passive recipients of your services.
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Remember to consider the impact of your decisions on your staff as well as the public.
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Record which organisations and protected characteristic groups you engaged with, when you engaged with them and how you did so (for example, workshop, public meeting, written submission).
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Produce a summary table describing the issues affecting each protected group and what the potential mitigations are.
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Report on positive impacts as well as negative ones.
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Remember what the Equality Act says – how can this policy or decision help foster good relations between different groups?
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Do it with other people! Talk to colleagues, bounce ideas, seeks views and opinions. |
[1] http://nww.cardiffandvale.wales.nhs.uk/portal/page?_pageid=253,73860407,253_73860411&_dad=portal&_schema=PORTAL
[2] http://nww2.nphs.wales.nhs.uk:8080/PubHObservatoryProjDocs.nsf
[3] http://www.cardiffandvaleuhb.wales.nhs.uk/the-challenges-we-face
[4] https://www.equalityhumanrights.com/en/human-rights/human-rights-act