1. Health Equity Audit SEPHIG Meeting May 2004 Liz Rolfe Sarah McBeath South East Public Health Observatory

2. In this presentation we aim to… 1.Define equity and Health Equity Audit 2.Describe the Health Equity Audit cycle –Particular focus on equity profiling, outlining the data and information available –Overview of new data developments 3.Examine the current policy context and how to take health equity audit forward locally 4.Signpost sources of information and support

3. Equity in healthcare Definition Equal access to available care for equal need Equal utilisation for equal need Equal quality of care for all (M. Whitehead, WHO, 1990)

4. Background Black Report (1980) Acheson Inquiry into Inequalities in Health (1998) Saving lives : Our Healthier Nation White Paper (1999) National Service Framework for Coronary Health Disease (2000)

5. What is Health Equity Audit? Comparing the provision of a service with a measure of the need for it (equity not equality)

6. Health Equity Outcome the desirable situation Service Measure of need

7. Stages of health equity audit

8. Where to start – agree priorities and partners Choose issue(s) with highest impact Identify factors driving low life expectancy Relate issues to service planning & commissioning –take opportunities where changes are planned Views of front line staff and users Fully engage with partners 1

9. What can we audit? Think!: well-known, well-described inequities from the literature Think!: local priority areas, existing expertise, knowledge and information Think!: Importance of issue in terms of health burden, financial consequences, potential health gain, disadvantaged populations or national priority

10. Who to involve? Example: Ayrshire and Arran NHS Board Inequalities Working Group conducted a Cardiac Disease Equity Audit which involved the following people: Director of Public Health Health Economist Public Health Specialist Senior Health Intelligence Officer Performance Manager Health Improvement Manager Health Intelligence Manger

11. Creating your equity profile Collect and analyse data on need and health inequalities –Identify measures for disadvantage –Focus on population with poorest health outcomes –Identify data sources Compare service provision with need, access, use & outcomes Identify the gaps 2

12. Data and indicators Need locally available and robust inequalities indicators Try and use routinely available existing data Data needs to be available within the timescale of the HEA

13. Examples of data that can be used in equity profiling… Vital statistics – births and deaths e.g. Compendium of Clinical and Health Indicators, ONS Births and Deaths files –To show variations in life expectancy, mortality, IMR, birth weight by area, sex, cause, social class… Morbidity data e.g. from Hospital Episode statistics (HES), GP registers, primary care clinical audit, communicable disease statistics –To show variations in prevalence or utilisation by area, sex, cause, social class… Local authority and ward data e.g. Best Value Performance Indicators (BVPI), Neighbourhood statistics, the 2001 census –Socio-economic profiles/ broad determinants Service utilisation –Activity data –Coverage data e.g. screening, immunisation Resource allocation

14. Examples of indicators Index of multiple deprivation Primary care professionals per population Patients on waiting lists for 6 months Age-standardised mortality rate for accidents MMR vaccinations Flu immunisation of over 65s Source: local basket of indictors

15. Opportunities & obstacles HEA may reveal local data needs or data quality issues Making better use of imperfect data and proxies Need good understanding of data Partnership working –with other PCTs –Data experts, e.g. PHOs

16. Examples: health equity audit topics Routine hospital procedures by CHD mortaility and deprivation index Distribution of GP clinics/health visitors by area deprivation index Uptake of aspirin/prescribing of Statins in patients with CHD by age/sex/deprivation Uptake of flu vaccinations by age for the over 50s

17. Uptake of Aspirin in patients recorded in primary care as having CHD by age band and sex, in Cambridgeshire and Peterborough Public Health Network area. An example of inequality between ages and sexes. Source: ERPHO. Heath A, King P, Lea D, Whyman H. PRIMIS Data Briefing 1. Cambridge: Cambridgeshire and Peterborough Mental Health Network; 2002

18. The relationship by between male mortality and revascularisation rates by PCT, East of England, 2000-2001 All rates are directly age- standardised to the East of England population. An example of geographical inequality. Sources: ERPHO: ref; 21 Hospital Episode Statistics

19. New data developments Local basket of indicators –A menu of local measures Index of Multiple Deprivation 2004 Health Poverty index –Visualisation tool for comparing health outcomes in different areas nGMS Quality and Outcome framework indicators

20. Local basket of indicators Led by the London Health Observatory Around 70 indicators measuring aspects of inequalities relating to health Available at LA or PCT level Large enough numbers to be useable Identifies indicators to be developed

21. Local basket of indicators For each indicator – –Definition –Govnt dept/policy area –Level of availability –Data source –Publication status –Publication details –Which indicator set –Frequency – Collected (locally or centrally) – Who collects data – Gender – Ethnicity – SEG – Geography – Age – Disability http://www.lho.org.uk/HIL/Inequalities_In_Health/Basket_Of_Indicators/Basket.htm Available at:

22. Health Poverty index A new web tool in development Allows a rapid comparison of ‘groups’ and their ‘health situation’ Includes health determinant indicators Variety of outputs: –Tables of HPI scores –Bar charts –Spider diagrams

23. Health Poverty index 1.0 corresponds to the best situation and 0.0 to the worst situation

24. http://www.dh.gov.uk/PolicyAndGuidance/HumanResourcesA ndTraining/ModernisingPay/GPContracts/fs/en nGMS contract: Quality and Outcome framework, Annex A: Quality Indicators – Summary of Points

25. Stages of health equity audit

26. Identify effective local action Understanding causal pathways –why has inequity occurred? What local interventions might help? –Are there examples of effective action? What is feasible and affordable? Tackling a health inequalities framework will: –Strengthen those in disadvantaged circumstances –Improve provision of and access to essential services and facilities –Encourage macro-economic and social change 3

27. Set targets for action Prioritise for local action –the ‘highest impact’ interventions – areas of greatest local need Identify what should happen to who and by how much Targets should be clear and signed up to by all 4

28. Secure changes in investment and service delivery Move resources and change service delivery to address inequities Ensure changes in contracts & commissioning to specify equity of access Are partners addressing inequities through their services? 5

29. Monitor and review Vital to close the loop Set up effective monitoring systems Review and assess progress –has change been made and is it fast enough? Identify where more action is required Put in place a regular review process 6

30. Monitor and Review example: Revascularisation 1997-2000 ERPHO: HES, PCT Dataset

31. Remember… The cycle is not complete until an improvement in inequities is achieved More than about creating an equity profile

32. In this presentation we aim to… 1.Define equity and Health Equity Audit 2.Describe the Health Equity Audit cycle –Particular focus on equity profiling, outlining the data and information available –Overview of new data developments 3.Examine the current policy context and how to take health equity audit forward locally 4.Signpost sources of information and support

33. Current policy context… 1.Tackling Health Inequalities: A Programme for Action 2.The Planning and Priorities Framework for 2003-06 3.Performance Indicators: Star Ratings 4.Wanless: Securing good health for the whole population: Final report - Feb 2004 5.New GMS contract: Quality indicators. 6.Choosing Health consultation and forthcoming White Paper

34. Current policy context 1… Tackling Health Inequalities: A Programme for Action http://www.dh.gov.uk/assetRoot/04/01/93/6204019362.pdf The Planning and Priorities Framework for 2003-06

35. Current policy context 2… Performance Indicators: Star Ratings 2003/04 Assessment of the effective use of health equity auditing in service planning, commissioning and delivery in order to tackle health inequalities 2004/05? Not yet, but… “Other (balanced scorecard) indicators will be released later in 2004.” http://www.chi.nhs.uk/eng/ratings/2005/index.shtml

36. Current policy context 3… Wanless: Securing good health for the whole population: Final report - Feb 2004 New GMS contract: Quality indicators. Choosing Health consultation and forthcoming White Paper

37. Sounds like a lot of work!!… Lack of capacity and resources to build up expertise in light of other priority areas??? ‘Re-branding’ exercise – area profiling, benchmarking, descriptions of health needs. Fit HEA into current planning cycles PCTs will incorporate HEA in different ways Broad range of things you can do equity audit on – link to existing priority areas, e.g. Coronary heart disease, teenage pregnancy.

38. Taking health equity audit forward: an example of self assessment Self assessment used to examine organisational issues surrounding implementing HEA Milton Keynes PCT Board and Executive Committee, March 2004

39. Key areas identified for action Finish development of social inclusion and health inequalities programme, DPH, Autumn 2004 Ensure organisational machinery exists to respond effectively to agenda, March 2005 –Mental health, Dir(Mental health services) –Workforce planning, Dir(Human resources) Investigate availability, quality and completeness of ethnicity data, DPH & Dir Fin(information), July 2004 Undertake equity audit of CHD and diabetes as part of PCT audit programmes 2004/05, Dir Clinical Gov, March 2005

40. How can SEPHO help? A collection of information on health equity audit on the SEPHO website. www.sepho.org.uk Potential to build up a resource of examples of local practice and knowledge Support in understanding data sources and data manipulation Any suggestions?

41. Summary Well developed guidelines and process for conducting health equity audit Relevant to current (and future) policy development ‘Rebranding exercise’ Think carefully about: a) Topics/areas to audit b) Data available for use Utilise existing examples of audits developed locally and sources of information, data and support to assist in the process

42. Sources of information on Health Equity Audit Health Equity Audit Made Simple http://www.hda.nhs.uk Department of Health http://www.dh.gov.uk/Home/fs/en APHO website http://www.pho.org.uk SEPHO website http://www.sepho.org.uk Health Poverty Index http://hpi.org.uk/index.php Local basket of indicators http://www.lho.org.uk/HIL/Inequalities_In_Health/Basket_Of_Indicators/Basket. htm ODPM Local Government Performance (Best Value Performance Indicators) http://www.bvpi.gov.uk/pages/Index.asp NCHOD (NHS access) (Compendium of Clinical and Health Indicators) http://nww.nchod.nhs.uk/ Office for National Statistics (Neighbourhood Statistics, Census, Vital Statistics) http://www.statistics.gov.uk/ ODPM (Indices of Multiple Deprivation 2004) http://www.odpm.gov.uk/stellent/groups/odpm_control/documents/contentserv ertemplate/odpm_index.hcst?n=4610&l=3