Yorkshire and Humber Vascular Services â€“ Patient and Public Survey 1
In what capacity are you responding to this survey?
a) b) c) d) e) f) g)
As an existing vascular services patient As a former vascular services patient (within the last five years) As a carer or family member of a vascular services patient On behalf of a patient group or community group On behalf of a partner organisation I have no experience to date of vascular services Other - Please state below ____________________________________
What is the name of your local Hospital?
Have you ever used a vascular service? If No, please jump to question 11.
Which hospital did you have your main operation at?
Were you admitted as an emergency?
How long did you have to travel to get to the hospital where you had your operation or treatment? a) Up to 1 hour
b) Between 1 & 2 hours
c) Over 2 hours
Page 1 of 7
How did you travel to the hospital for your operation or treatment? Please tick one
a) b) c) d) e) f)
Ambulance Medicar (Patient Transport Services) Drove myself Friend/relative/carer drove me Public transport Other â€“ Please state below ____________________________________
Was all your care (appointments, treatments and hospital stay) carried out in one hospital? If you answer YES, please jump to question 10. Yes No
If you answered NO to question 8, which of the following part(s) of your care were carried out at your local hospital?
Yes a) b) c) d) e) f) g) h)
My first outpatient appointment Other outpatient appointments My pre-assessment appointment My admission to hospital My operation I was transferred back to my local hospital straight after my operation My long-term follow-up with the surgeon My rehabilitation with physiotherapists
How would you rate the care you received within vascular services at: Very good
Your local hospital The hospital where you had your main operation (if different)
Page 2 of 7
If you were going to be treated by a vascular service in the future, please rank the following items between 1 and 8 in order of their importance to you: 1 = most important 8 = least important
a) b) c) d) e) f) g) h)
How experienced in doing the operation the surgeon was Getting the best possible treatment for my condition Having the best possible chance of surviving the operation How far I would have to travel for my procedure How far I would have to travel for my outpatients appointments How easily I could get to the hospital How easily my family/friends/carers could visit me in hospital Is there anything else that you think is important which is missing from the list?
How would you expect to get to the hospital if you needed a planned operation?
a) b) c) d) e)
Medicar (Patient Transport Services) Drive myself Friend/relative/carer would drive me Public transport Other - Please state below ____________________________________
Would you be willing to travel further than your local major hospital with an A&E department for an operation by a consultant specialising in vascular operations and procedures? Yes No
Would you be willing to travel further than your local major hospital with an A&E department for an appointment by a consultant specialising in vascular operations and procedures? Yes No
If you had to have an operation at a hospital specialising in vascular procedures rather than your local hospital, would you like to be transferred back to your local hospital after the operation? Yes No
Page 3 of 7
If you had to travel further for care by a professional specialising in vascular operations, what issues would we need to take into consideration?
17 Are there any other comments you would like us to consider?
If you would like to have further involvement with this work or work to improve other SCG services, or if you would like to receive information about the progress of this review, please tick the appropriate box(es). Please let us know how to contact you by writing-in your contact details in â€˜eâ€™ below.
a) b) c) d)
Take part in a discussion group (in person) Take part in an on-line discussion group Take part in future work to improve services I would like to receive further information about the progress of this review
e)_________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Page 4 of 7
Equality Monitoring The Specialised Commissioning Group (SCG) is committed to ensuring that all its services are delivered fairly to everyone. We need to be able to check how well weâ€™re doing this, which is why we are asking you the following questions about yourself. The information you provide will be kept confidential, but may be used by the SCG to check the fairness of any other services you receive. You do not have to answer these questions, and it will make no difference at all to the way you are treated whether you answer them or not. Gender Are you? Male Age What is your date of birth?
What is your age?
0-16 17-20 21-30 31-40 41-50
51-60 61-70 71-80 81+
Disability Are you disabled? (A disabled person can be someone with a physical or sensory impairment, learning difficulties, mental health problems or a long term or progressive medical condition.) Yes No Blind/partially sighted Deaf/hearing If yes, please impairment tick the Wheelchair user relevant Mobility difficulties box/es Mental health difficulties Long term illness Dyslexia Learning disability Other - Please state:
Page 5 of 7
Ethnicity What is your ethnic origin? (please tick one only) White
British Irish European Gypsy / Traveller Other - Please state:
White & Black Caribbean White and Black African White and Asian Other - Please state:
Black or Black British
Caribbean African Other - Please state:
Asian or Asian British
Chinese or other ethnic group
Indian Pakistani Bangladeshi Other - Please state:
Other - Please state:
Religion and Belief What is your religion? Christian Muslim Hindu Buddhist Other - Please state:
Jewish Sikh Rastafarian No religion
Sexual Orientation How would you describe your sexual orientation?
Heterosexual Lesbian Prefer not to answer Other - Please state:
Page 6 of 7
Gender Identity Do you consider yourself to be transgender? (For example, have you considered, or do you plan to have, surgery to change your sex). Yes Prefer not to answer
If you would like this information in another format, such as large print or another language, please call 01226 43 3682, or email: firstname.lastname@example.org. Если вы хотите получить эту информацию в другом формате, например большим шрифтом или на другом языке, пожалуйста позвоните по телефону 01226 43 3682, или шлите электронную почту по адресу: email@example.com 01226 43
م2/ اﮦ2= ،*M ز=(ن2J.( د. ﭧ:2; 5@?ﮯ =ﮍA ،ﮯC(ﮨE )@ﮟGHI 526*)(ت دو+,) ہ. */ پ1 23ا @ﮟ۔Q@R= G@) 5 ا2; firstname.lastname@example.org (. ،ﮟ.2/ (ل/ 2; 3682
Your views are important to us, thank you for telling us what you think. The final date for us to receive this completed questionnaire is Friday, 28th May 2010 If you have any queries please telephone the Consultation and Engagement Team (SCG) on: 01226 433683. Our address is: Consultation and Engagement Team, NHS Barnsley, Hillder House, 49/51 Gawber Road, Barnsley, S75 2PY
Page 7 of 7
Published on May 27, 2010