Please complete this questionnaire to help us work with you to complete your local impact assessment.
Name:
Email:
Tel:
Organisation: Select Organisation 5 Boroughs Partnership NHS Trust Aintree University Hospitals NHS Foundation Trust Airedale NHS Trust Ashford And St Peters Hospitals NHS Trust Ashton, Leigh And Wigan PCT Avon And Wiltshire Mental Health Partnership NHS Trust Bad Code Barking And Dagenham PCT Barking, Havering And Redbridge Hospitals NHS Trust Barnet And Chase Farm Hospitals NHS Trust Barnet PCT Barnet, Enfield And Haringey Mental Health NHS Trust Barnsley Hospital NHS Foundation Trust Barnsley PCT Barts And The London NHS Trust Basildon And Thurrock University Hospitals NHS Foundation Trust Basingstoke And North Hampshire NHS Foundation Trust Bassetlaw PCT Bath And North East Somerset PCT Bedford Hospital NHS Trust Bedfordshire And Luton Mental Health And Social Care NHS Trust Bedfordshire PCT Berkshire East PCT Berkshire Healthcare NHS Foundation Trust Berkshire West PCT Bexley Care Trust Birmingham And Solihull Mental Health NHS Trust Birmingham Childrens Hospital NHS Foundation Trust Birmingham East And North PCT Birmingham Womens Health Care NHS Trust Blackburn With Darwen PCT Blackpool PCT Blackpool, Fylde And Wyre Hospitals NHS Trust Bolton Hospitals NHS Trust Bolton PCT Bournemouth And Poole PCT Bradford And Airedale Teaching PCT Bradford District Care Trust Bradford Teaching Hospitals NHS Foundation Trust Brent Teaching PCT Brighton And Hove City PCT Brighton And Sussex University Hospitals NHS Trust Bristol PCT Bromley Hospitals NHS Trust Bromley PCT Brook Buckinghamshire Hospitals NHS Trust Buckinghamshire PCT Burton Hospitals NHS Trust Bury PCT Calderdale And Huddersfield NHS Foundation Trust Calderdale PCT Calderstones NHS Trust Cambridge University Hospitals NHS Foundation Trust Cambridgeshire And Peterborough Mental Health Partnership NHS Trust Cambridgeshire PCT Camden And Islington Mental Health And Social Care Trust Camden PCT Central And Eastern Cheshire PCT Central And North West London NHS Foundation Trust Central Lancashire PCT Central Manchester And Manchester Children'S University Hospitals NHS Trust Chelsea And Westminster Hospital NHS Foundation Trust Cheshire And Wirral Partnership NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust Christie Hospital NHS Foundation Trust City And Hackney Teaching PCT City Hospitals Sunderland NHS Foundation Trust Clatterbridge Centre For Oncology NHS Foundation Trust Cornwall And Isles Of Scilly PCT Cornwall Partnership NHS Trust Countess Of Chester Hospital NHS Foundation Trust County Durham And Darlington NHS Foundation Trust County Durham PCT Coventry And Warwickshire Partnership NHS Trust Coventry Teaching PCT Croydon PCT Cumbria Partnership NHS Foundation Trust Cumbria PCT Darlington PCT Dartford And Gravesham NHS Trust Derby City PCT Derby Hospitals NHS Foundation Trust Derbyshire County PCT Derbyshire Mental Health Services NHS Trust Devon Partnership NHS Trust Devon PCT Doncaster And Bassetlaw Hospitals NHS Foundation Trust Doncaster PCT Dorset Healthcare NHS Foundation Trust Dorset PCT Dudley Group Of Hospitals NHS Trust Dudley PCT Ealing Hospital NHS Trust Ealing PCT East And North Hertfordshire NHS Trust East And North Hertfordshire PCT East Cheshire NHS Trust East Kent Hospitals NHS Trust East Lancashire Hospitals NHS Trust East Lancashire PCT East London NHS Foundation Trust East Midlands Ambulance Service NHS Trust East Of England Ambulance Service NHS Trust East Riding Of Yorkshire PCT East Sussex Downs And Weald PCT East Sussex Hospitals NHS Trust Eastern And Coastal Kent PCT Enfield PCT Epsom And St Helier University Hospitals NHS Trust Essex Rivers Healthcare NHS Trust Frimley Park Hospital NHS Foundation Trust Gateshead Health NHS Foundation Trust Gateshead PCT George Eliot Hospital NHS Trust Gloucestershire Hospitals NHS Foundation Trust Gloucestershire Partnership NHS Foundation Trust Gloucestershire PCT Great Ormond Street Hospital For Children NHS Trust Great Western Ambulance Service NHS Trust Great Yarmouth And Waveney PCT Greater Manchester West Mental Health NHS Foundation Trust Greenwich Teaching PCT Guy's And St Thomas' NHS Foundation Trust Halton And St Helens PCT Hammersmith And Fulham PCT Hampshire Partnership NHS Trust Hampshire PCT Haringey Teaching PCT Harrogate And District NHS Foundation Trust Harrow PCT Hartlepool PCT Hastings And Rother PCT Havering PCT Heart Of Birmingham Teaching PCT Heart Of England NHS Foundation Trust Heatherwood And Wexham Park Hospitals NHS Trust Hereford Hospitals NHS Trust Herefordshire PCT Hertfordshire Partnership NHS Foundation Trust Heywood, Middleton And Rochdale PCT Hillingdon PCT Hinchingbrooke Health Care NHS Trust Homerton University Hospital NHS Foundation Trust Hounslow PCT Hull And East Yorkshire Hospitals NHS Trust Hull Teaching PCT Humber Mental Health Teaching NHS Trust Imperial College Healthcare NHS Trust Ipswich Hospital NHS Trust Isle Of Wight NHS PCT Islington PCT James Paget University Hospitals NHS Foundation Trust Kensington And Chelsea PCT Kent And Medway NHS And Social Care Partnership Trust Kettering General Hospital NHS Trust Kings College Hospital NHS Foundation Trust Kingston Hospital NHS Trust Kingston PCT Kirklees PCT Knowsley PCT Lambeth PCT Lancashire Care NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds Partnerships NHS Foundation Trust Leeds PCT Leeds Teaching Hospitals NHS Trust Leicester City PCT Leicestershire County And Rutland PCT Leicestershire Partnership NHS Trust Lewisham PCT Lincolnshire Partnership NHS Foundation Trust Lincolnshire Teaching PCT Liverpool PCT Liverpool Women'S NHS Foundation Trust London Ambulance Service NHS Trust Luton And Dunstable Hospital NHS Foundation Trust Luton PCT Maidstone And Tunbridge Wells NHS Trust Manchester Mental Health And Social Care Trust Manchester PCT Mayday Healthcare NHS Trust Medway NHS Trust Medway PCT Mersey Care NHS Trust Mid Essex Hospital Services NHS Trust Mid Essex PCT Mid Staffordshire General Hospitals NHS Trust Mid Yorkshire Hospitals NHS Trust Middlesbrough PCT Milton Keynes General Hospital NHS Trust Milton Keynes PCT Moorfields Eye Hospital NHS Foundation Trust Newcastle PCT Newham PCT Newham University Hospital NHS Trust No Code Norfolk And Norwich University Hospital NHS Trust Norfolk And Waveney Mental Health NHS Foundation Trust Norfolk PCT North Bristol NHS Trust North Cheshire Hospitals NHS Trust North Cumbria Acute Hospitals NHS Trust North East Ambulance Service NHS Trust North East Essex PCT North East Lincolnshire PCT North East London Mental Health NHS Trust North Essex Partnership NHS Foundation Trust North Lancashire PCT North Lincolnshire PCT North Middlesex University Hospital NHS Trust North Somerset PCT North Staffordshire Combined Healthcare NHS Trust North Staffordshire PCT North Tees And Hartlepool NHS Trust North Tees PCT North Tyneside PCT North West Ambulance Service NHS Trust North West London Hospitals NHS Trust North Yorkshire And York PCT Northampton General Hospital NHS Trust Northamptonshire Healthcare NHS Trust Northamptonshire Teaching PCT Northern Devon Healthcare NHS Trust Northern Lincolnshire And Goole Hospitals NHS Foundation Trust Northumberland Care Trust Northumberland, Tyne And Wear NHS Trust Northumbria Healthcare NHS Foundation Trust Nottingham City PCT Nottingham University Hospitals NHS Trust Nottinghamshire County Teaching PCT Nottinghamshire Healthcare NHS Trust Nuffield Orthopaedic Centre NHS Trust Oldham PCT Out Of London Oxford Radcliffe Hospitals NHS Trust Oxfordshire And Buckinghamshire Mental Health Partnership NHS Trust Oxfordshire Learning Disability NHS Trust Oxfordshire PCT Oxleas NHS Foundation Trust Papworth Hospital NHS Foundation Trust Pennine Acute Hospitals NHS Trust Pennine Care NHS Trust Peterborough And Stamford Hospitals NHS Foundation Trust Peterborough PCT Plymouth Hospitals NHS Trust Plymouth Teaching PCT Poole Hospital NHS Trust Portsmouth City Teaching PCT Portsmouth Hospitals NHS Trust Queen Elizabeth Hospital NHS Trust Queen Marys Sidcup NHS Trust Queen Victoria Hospital NHS Foundation Trust Redbridge PCT Redcar And Cleveland PCT Richmond And Twickenham PCT Robert Jones And Agnes Hunt Orthopaedic And District Hospital NHS Trust Rotherham PCT Rotherham, Doncaster And South Humber Mental Health NHS Foundation Trust Royal Berkshire NHS Foundation Trust Royal Brompton And Harefield NHS Trust Royal Cornwall Hospitals NHS Trust Royal Devon And Exeter NHS Foundation Trust Royal Free Hampstead NHS Trust Royal Liverpool And Broadgreen University Hospitals NHS Trust Royal Liverpool Childrens NHS Trust Royal National Orthopaedic Hospital NHS Trust Royal Surrey County Hospital NHS Trust Royal United Hospital Bath NHS Trust Royal West Sussex NHS Trust Salford PCT Salford Royal NHS Foundation Trust Salisbury NHS Foundation Trust Sandwell And West Birmingham Hospitals NHS Trust Sandwell Mental Health NHS And Social Care Trust Sandwell PCT Scarborough And North East Yorkshire Health Care NHS Trust Sefton PCT Sheffield Care Trust Sheffield Childrens NHS Foundation Trust Sheffield PCT Sheffield Teaching Hospitals NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation Trust Shrewsbury And Telford Hospital NHS Trust Shropshire County PCT Solihull Care Trust Somerset Partnership NHS And Social Care Trust Somerset PCT South Birmingham PCT South Central Ambulance Service NHS Trust South Devon Healthcare NHS Foundation Trust South Downs Health NHS Trust South East Coast Ambulance Service NHS Trust South East Essex PCT South Essex Partnership NHS Foundation Trust South Gloucestershire PCT South London And Maudsley NHS Foundation Trust South Staffordshire And Shropshire Healthcare NHS Foundation Trust South Staffordshire PCT South Tees Hospitals NHS Trust South Tyneside NHS Foundation Trust South Tyneside PCT South Warwickshire General Hospitals NHS Trust South West Essex PCT South West London And St George'S Mental Health NHS Trust South West Yorkshire Mental Health NHS Trust South Western Ambulance Service NHS Trust Southampton City PCT Southampton University Hospitals NHS Trust Southend University Hospital NHS Foundation Trust Southport And Ormskirk Hospital NHS Trust Southwark PCT St Georges Healthcare NHS Trust St Helens And Knowsley Hospitals NHS Trust Stockport NHS Foundation Trust Stockport PCT Stoke On Trent PCT Suffolk Mental Health Partnership NHS Trust Suffolk PCT Sunderland Teaching PCT Surrey And Borders Partnership NHS Trust Surrey And Sussex Healthcare NHS Trust Surrey PCT Sussex Partnership NHS Trust Sutton And Merton PCT Swindon And Marlborough NHS Trust Swindon PCT Tameside And Glossop Acute Services NHS Trust Tameside And Glossop PCT Taunton And Somerset NHS Trust Tavistock And Portman NHS Foundation Trust Tees, Esk And Wear Valleys NHS Trust Telford And Wrekin PCT The Cardiothoracic Centre - Liverpool NHS Trust The Hillingdon Hospital NHS Trust The Lewisham Hospital NHS Trust The Mid Cheshire Hospitals NHS Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust The Princess Alexandra Hospital NHS Trust The Queen Elizabeth Hospital Kings Lynn NHS Trust The Rotherham NHS Foundation Trust The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust The Royal Marsden NHS Foundation Trust The Royal National Hospital For Rheumatic Diseases NHS Foundation Trust The Royal Orthopaedic Hospital NHS Foundation Trust The Royal Wolverhampton Hospitals NHS Trust The Whittington Hospital NHS Trust Torbay Care Trust Tower Hamlets PCT Trafford Healthcare NHS Trust Trafford PCT United Bristol Healthcare NHS Trust United Lincolnshire Hospitals NHS Trust University College London Hospitals NHS Foundation Trust University Hospital Birmingham NHS Foundation Trust University Hospital Of North Staffordshire NHS Trust University Hospital Of South Manchester NHS Foundation Trust University Hospitals Coventry And Warwickshire NHS Trust University Hospitals Of Leicester NHS Trust University Hospitals Of Morecambe Bay NHS Trust Wakefield District PCT Wales Walsall Hospitals NHS Trust Walsall Teaching PCT Waltham Forest PCT Walton Centre For Neurology And Neurosurgery NHS Trust Wandsworth PCT Warrington PCT Warwickshire PCT West Dorset General Hospitals NHS Trust West Essex PCT West Hertfordshire Hospitals NHS Trust West Hertfordshire PCT West Kent PCT West London Mental Health NHS Trust West Middlesex University Hospital NHS Trust West Midlands Ambulance Service NHS Trust West Suffolk Hospitals NHS Trust West Sussex PCT Western Cheshire PCT Westminster PCT Weston Area Health NHS Trust Whipps Cross University Hospital NHS Trust Wiltshire PCT Winchester And Eastleigh Healthcare NHS Trust Wirral Hospital NHS Trust Wirral PCT Wolverhampton City PCT Worcestershire Acute Hospitals NHS Trust Worcestershire Mental Health Partnership NHS Trust Worcestershire PCT Worthing And Southlands Hospitals NHS Trust Wrightington, Wigan And Leigh NHS Trust Yeovil District Hospital NHS Foundation Trust York Hospitals NHS Foundation Trust Yorkshire Ambulance Service NHS Trust
Name (if other):
Code:
GUMAMM First Appointment Activity:
GUMAMM Follow-up Activity:
GUM Spend (including MFF):
Number of SRH Contacts
Estimated Spend on SRH Activity:
Language: please select High Med Low
Vulnerable Groups (age under 16, disability, mental health): please select High Med Low
High Risk (drug/alcohol abuse, sex workers): please select High Med Low
Co-morbidity: please select High Med Low
High cultural variance across the population: please select High Med Low
Deprivation of population as a whole: please select High Med Low
Other:
Level of Confidence in these Figures: please select High Med Low
Comments:
Thank you for participating. If you have any questions please contact enquiries@pathwayanalytics.com