1. Health equity audit Stuart Harris Public Health Intelligence Analyst Course – Day 4

2. 2 Learning objectives Health equity audit 1.To understand what is meant by Health Equity Audit (HEA) 2.To understand the processes behind HEA 3.To increase awareness, through an example, of how HEA may be applied in practice

3. 3 also along the way.... sources of information on comparative levels of need tensions between different policy agendas: ‒ reducing inequalities ‒ achieving equity ‒ the choice agenda Health equity audit

4. 4 Defining health equity audit Health equity audit “HEA is a process for identifying how fairly services or other resources are distributed in relation to the health needs of different groups and areas, and the priority action to provide services relative to need. The overall aim is not to distribute resources equally but, rather, relative to health need. The purpose is for health and other services to help narrow health inequalities by taking positive decisions on investment, service planning, commissioning and delivery that narrow inequalities.”

5. 5Health equity audit health inequality.... and health equity Health inequality Differences in health experience between population groups differing in terms of e.g. geography, age, sex, ethnicity, socio- economic status Health equity “Fair” distribution of health/health care resources or opportunities according to population need Allocating relatively more resources where there is relatively more need Equal quality of care for all

6. 6Health equity audit health inequality.... and health equity If all LAs in England have a Coronary Artery Bypass Graft rate of 750 operations per 1,000,000 pop this is equality but is probably not equitable - some LAs will have a higher level of need.

7. 7 Health equity Health equity audit Service x y Measure of Need

8. 8 Health inequity Health equity audit Inequity : those with most need get the lowest level of service - the undesirable “inverse care law” Service x y Measure of Need

9. 9 Health equity audit cycle Health equity audit

10. 10 Why conduct health equity audit? Health equity audit To ensure that effective interventions are provided for all groups in the population, targeting those with highest need Are the services / interventions available to the people who need them? Are the people who need the services accessing the services?

11. 11 Health equity audit – general approach Health equity audit Method: -Measure the need (‘need’); -Measure those using the service (‘use’); -Analysis of gap between ‘need’ and ‘use’; -Action to ensure more equitable service; -Monitor / review But data can be a barrier – especially in quantifying need

12. 12 Example of health equity audit Health equity audit The following slides give an example of a health equity audit in the East Midlands – an evaluation of Stop Smoking Services in Nottingham (New Leaf) Audit uses geographic and geodemographic information systems to measure equity of service

13. 13 New Leaf equity audit Health equity audit Need: Mosaic Groups’ smoking index Use: New Leaf service users’ postcodes

14. 14 Estimating need and use Health equity audit

15. 15 Comparing use with need (?) Health equity audit G N H

16. 16 Estimating need and use (?) Health equity audit

17. 17 Comparing use with need (?) Health equity audit M N H G

18. 18 Where do the smokers live? Health equity audit

19. 19 Evidence-based service delivery Health equity audit Health equity audit provided evidence for commissioners Action to address gaps ‒ Engaging the New Leaf team ‒ More proactive work with practices in ‘cold spot’ areas ‒ Pharmacy-based cessation service ‒ Social marketing stop smoking campaign

20. 20 Evidence of improvement Health equity audit

21. 21 Where do New Leaf service users live? Health equity audit

22. 22 Is there a gap? Health equity audit Lenton Abbey Low uptake but high smoking groups I and O Inner Nottingham – low uptake but high smoking groups N and I

23. 23 Monitoring period; July 07 to July 2010 Health equity audit

24. 24 Conclusions Health equity audit Mosaic a very useful tool for HEA (?) Needs to be part of regular performance management of contracts Addresses some of the data barriers

25. 25 Sources of information on variations in need Health equity audit estimates from national surveys of comparative levels of need in different age/gender/ethnic/deprivation groups ‒ Integrated Household Survey ‒ National Census local surveys modelled prevalence data ‒ hypertension, CHD, diabetes, COPD, etc (http://www.apho.org.uk/diseaseprevalencemodels) ‒ synthetic estimates of health-related lifestyle (available on Neighbourhood Statistics website)

26. 26 Sources of information on variations in need Health equity audit NHS data - primary care records, hospital episodes, Is this an appropriate source? NHS data is generally generated from service usage data, and thus reflects need combined with access, rather than need alone.

27. 27 Reducing inequalities v. achieving equity Health equity audit Should the goal be no inequalities in need or... Inequalities in access that match the inequalities in need or … Inequalities in outcome that match the inequalities in need? Tensions between achieving equity, ensuring availability to all, allowing choice, reaching targets

28. 28Health equity audit Tensions between reducing inequalities, achieving equity and the choice agenda “Evidence from the USA suggests that vulnerable patients, including those from black and other minority ethnic groups are increasingly excluded as a result of extending choice. An increase in inequity seems inevitable unless the choice policy includes a means of targeting disadvantaged groups... to prevent such exclusion.” NHS Service Delivery and Organisation Research & Development Programme, Nov 2006

29. 29 Health equity audit cycle Health equity audit

30. 30 Step 3: Identify effective local action Health equity audit Understanding why the inequity is occurring? What local interventions might help? ‒ Are there examples of effective action elsewhere? ‒ Prioritise highest impact interventions What is feasible and affordable?

31. 31 Step 4: Set targets for action Health equity audit Prioritise groups with the poorest level of service/greatest levels of unmet need Identify what should happen to who and by how much Targets should be clear and signed up to by all

32. 32 Step 5: Secure changes in investment and service delivery Health equity audit Move resources and change service delivery to address inequities Ensure changes in contracts & commissioning to specify equity of access

33. 33 Step 6: Monitor and review Health equity audit Vital to close the loop Set up effective monitoring systems and a regular review process Assess progress - have targets for action been achieved and inequity reduced? Identify whether and where more remedial action is required... and round the cycle again

34. 34 In conclusion Health equity audit 1.Different dimensions of equity - age, gender, ethnicity, social class, area of residence 2.Estimating comparative levels of need - can be a challenge 3.Sophistication/accuracy may not always be necessary 4.How to act on equity profiling information may not always be obvious 5.Need to explore “why is inequity occurring?” first 6.The importance of closing the loop - HEAs without follow- up action are potentially a waste of time