1. The London Health Observatory: monitoring health and health care in the capital, supporting practitioners and informing decision-makers Health equity audit- can it achieve a fairer use of resources for health? Dr Bobbie Jacobson OBE Director London Health Observatory Bologna, 26 June 2012

2. Bologna La Rossa Contro Londra la Grigia!

3. Presentation Overview Introduction to the UK Observatories What do we mean by inequity? Measuring equity-the challenges Health Equity Audit and how to use it effectively

4. The observatory network – what do we do now? We work in partnership to turn data into health intelligence to support decision-making on health and health care nationally and in our regions We are a network of regional hubs connected nationally for turning data into health intelligence ; signposting health knowledge in innovative ways We monitor, forecast and assess the impacts of policy on health in our regions We work with researchers, practitioners and the Department of Health to produce national e-tools, reports and advice to support local action We help build analytic/public health capacity in our local workforces

5. The observatory network and lead areas LHO lead areas: Health inequalities Ethnicity Smoking

6. The London Health Observatory: monitoring health and health care in the capital, supporting practitioners and informing decision-makers GENDER GEOGRAPHY SEXUALITY SOCIO-ECONOMIC GROUP DISABILITY AGE ETHNICITY Social-economic environment e.g. jobs, housing, education, transport Lifestyles/health behaviour e.g.. diets, smoking, social networks Access to effective health/social care e.g. services that result in health benefits Health outcomes e.g. increase/reduce mortality, morbidity, ill health, disability The Spectrum of inequity

7. How do we “decide” differences are inequitable? Let’s see…..

8. Inequity in causes? The example of unemployment

10. Are these differences equitable? Si, equo No, iniquo Non so

11. The London Health Observatory: monitoring health and health care in the capital, supporting practitioners and informing decision-makers Inequity in outcomes: are the differences in male life expectancy at birth across London inequitable?

13. Are these differences equitable? Si, equo No, iniquo Non so

14. Is spending on health care equitable? The example of mental health services

16. Is the variation in spend inequitable? Planned spend on direct mental health services varied from £58 per weighted population-£220 per weighted population

17. Are these differences Inequitable?

18. Actual and expected planned mental health spend per capita (16-64 years) by borough (2005/06)

19. The tricky business of measuring inequity - some questions How will we know we have reduced inequalities? Do we simply “bring up the floor”? Eg improve access to care for the homeless and migrants? Which dimensions of inequity to use? What is practical?

20. What is Health Equity Audit? Health Equity Audit is a process by which: partners systematically review inequities in the causes of ill health, and access to effective services and their outcomes, for a defined population ensure that further action is agreed and incorporated into policy, plans and practice. actions taken are reviewed to assess whether inequities have been reduced. Source: “Health Equity Audit Made Simple.” http://www.lho.org.uk/HIL/Inequalities_In_Health/Attachments/PDF_Files/equityauditfinal21.1.3.pdf

22. Source: “Health Equity Audit Made Simple.” http://www.lho.org.uk/HIL/Inequalities_In_Health/Attachments/PDF_Files/equityauditfinal21.1.3.pdf The cycle of Health Equity Audit 1. Agree priorities & partners 2. Do an equity profile 3. Identify effective local action to tackle inequalities 4. Agree local targets with partners 5. Secure changes in investment and service delivery 6. Review progress and impacts against targets

23. The English context for Health Equity Audit Introduced in 2004 during the Labour Government National targets set for reducing inequalities in health Made mandatory for 2-3 yrs as part of the national performance assessment framework for England Local NHS conducted the audit and gave a self assessment on its quality LHO supported & surveyed local organisations to understand what it was and how to do it

24. Audit progress – results of the LHO survey 2004 Key: 1Topic(s)/theme(s) under discussion 2Topic(s)/theme(s) agreed 3Health equity profile well under way/complete 4Objectives for further action agreed at PCT Board level 5Objectives for further action agreed by partner agencies 6Planning/resource commitments identified 7Planning/resource commitments and timescales agreed 8Findings/recommendations of HEA published 9PCT Board assessment process planned/underway

25. Top 10 topics selected 1. Coronary heart disease 2. Smoking cessation 3. Health care access 4. Health visiting and Children’s services 5. Diabetes 6. Neighbourhood initiatives 7. Cancers 8. Maternal and child health 9. Sexual health 10. Black and minority issues

26. Dimensions of inequity covered Key: 1 Geographical 6 Deprivation category 2Gender7 Sexual orientation 3Age 8 Disability 4Ethnicity 5Social class/socio economic group

27. Most common factors influencing choice of topic 1.Views of local leaders 2.Ability to deliver effective change locally 3.Manageable within resources available 4.Good evidence base for a health inequality gradient 5.Relevance to national health inequalities targets 6.Measurement and methods feasible at local level

28. Making a difference What is the evidence for “Closing the audit loop”?

29. Per cent 5 year olds achieving ‘good development score’,* Birmingham LA, West Midlands & England *in personal, social and emotional development and communication, language and literacy Source: Department for Education %

30. E ffective implementation of Health Equity Audit: key points Audit flourished in England during a period of national commitment to reducing inequalities Choice of successful audits and comparators is as much political & pragmatic as epidemiological Building engagement among relevant people/organisations needs “top team” commitment “population diagnosis” alone is not enough for effective equity audit ; implementation of change is equally important.

31. Useful resources The LHO : lead inequalities observatory: www.lho.org.ukwww.lho.org.uk DH Health Equity Audit: A Guide for the NHS http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic yAndGuidance/DH_4084138 Health Equity Audit Made Simple http://www.lho.org.uk/viewResource.aspx?id=7670 Health Equity Audit Made Simple: A briefing for Primary Care Trusts and Local Strategic Partnerships http://www.erpho.org.uk/viewResource.aspx?id=6773 Health Equity audit methods /case studies http://www.empho.org.uk/methodologies/hea/hea_casestudies.aspx Maternity audit and Database of case studies http://www.avon.nhs.uk/phnet/publications/hea/final_bristol_mat_hea_short_rep ort.pdf