Transcript An overview of public health and its practice

Health Equity Audit
Dr Jean Robinson
NHS Nottingham City
Learning Objectives
1. To understand what is meant by Health Equity
Audit (HEA)
2. To understand the drivers behind HEA
3. To increase awareness, through case studies, of
how HEA is applied in practice
also along the way ....
• sources of information on comparative levels
of need
• tensions between different policy agendas:
– reducing inequalities
– achieving equity
– the choice agenda
Defining HEA
1.
2.
3.
“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.”
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
If all PCTs 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 PCTs will
have a higher level of need.
Health Equity Audit compares the provision of a
service with a measure of the need for it
y
Service
x
Measure of Need
Equity : high need is matched by high service provision the desirable situation
y
Service
x
Measure of Need
Inequity : those with most need get the lowest
level of service - the undesirable
“inverse care law”
y
Service
x
Measure of Need
Drivers for HEA
NHS Planning Guidance 2005-2008:
PCTs...taking account of different needs and inequalities within the
local population …, on the basis of a systematic programme of health
equity audit and equality impact assessment…..using health equity
audit
NHS Planning Guidance 2010-2011:
five national priorities remain, including ‘keeping adults and
children well, improving their health and reducing health
inequalities’
…no mention of Equity tools, though do mention
JSNA.
Drivers for HEA
Accessible and responsive care:
Core standard C18
Healthcare organisations enable all
members of the population to access
services equally and offer choice in
access to services and treatment
equitably.
Public Health:
Core Standard C22a&c
The PCT actively works with other healthcare
organisations, local government and other
local partners to promote, protect and
demonstrably improve the health of the
community served and narrow health
inequalities, ……participating in JSNA and/or
health equity audits to identify population
health needs.
Cycle of health equity audit
6
Review progress
and impacts
against targets
5
Secure changes in
investment and
service delivery
1
Agree priorities
and partners
4
Agree local
targets with
partners
2
Equity
profile
3
Identify local
action to tackle
inequalities
Why conduct health equity audit?
•
To ensure that effective interventions are
provided for all groups in the population,
targeting those with highest need
•
Statutory requirement – Health care
Commission Core Standard C23
•
Are the services / interventions available
to the people who need them?
•
Are the people who need the services
accessing the services?
Template slide set
• The following slides give an example of HEA in the
East Midlands – Stop Smoking Services in Derbyshire
• Further examples are available in the accompanying
supplementary slide set
Using
Geographic and Geodemographic
Information Systems to measure Equity of service
Jeanelle de Gruchy, Consultant in Public Health
Jean Robinson, Head of Information
Indu Hari, Manager of New Leaf Stop Smoking Service
Health equity audit
• PCT requirement for effective commissioning
• 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
HEA New Leaf
• Commissioner and provider involved
• An innovative method to address barriers:
– Geographic Information System – MapInfo
– Geodemographic System – Mosaic Public Sector
HEA New Leaf
• Need: Mosaic Groups’ smoking index
• Use: New Leaf service users’ postcodes
Use and Need
Mosaic
Code
Mosaic Group Name
Nottingham
Population
2009
Smoking
Accessing
Index (Need) New Leaf
G
G Young, well-educated city dwellers
22.0
112
11.7
O
O Families in low-rise social housing with high levels of benefit need
20.0
160
30.1
I
I Lower income workers in urban terraces in often diverse areas
12.2
128
13.0
K
K Residents with sufficient incomes in right-to-buy social housing
11.9
133
14.5
N
N Young people renting flats in high density social housing
8.5
143
13.6
E
E Middle income families living in moderate suburban semis
5.6
85
3.1
J
J Owner occupiers in older-style housing in ex-industrial areas
5.2
101
4.0
M
M Elderly people reliant on state support
3.8
108
5.2
H
H Couples and young singles in small modern starter homes
3.4
112
2.2
B
B Residents of small and mid-sized towns with strong local roots
2.8
79
1.3
D
D Successful professionals living in suburban or semi-rural homes
2.0
59
0.5
L
L Active elderly people living in pleasant retirement locations
1.2
71
0.4
C
C Wealthy people living in the most sought after neighbourhoods
1.0
54
0.2
F
F Couples with young children in comfortable modern housing
0.5
77
0.2
New Leaf:
an equitable service by Group
35.0
% Accessing New Leaf by Mosaic Group
30.0
25.0
R2 = 0.9125
20.0
15.0
10.0
5.0
0.0
0
20
40
60
80
100
Need Index
120
140
160
180
Nottingham:
where do the smokers live?
Where do
New Leaf service users live?
Is there a gap?
Inner Nottingham – low
uptake but high smoking
groups N and I
Lenton Abbey
Low uptake but high
smoking groups I and O
Evidence-based service delivery
• HEA 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
Evidence of improvement
Baseline period (Apr 04 – Mar 06)
12 months later (Apr 04 – Mar 07)
Staff shortage
addressed
Improved
access
Low uptake
Monitoring period July 07 – June 2010
Uptake in Lenton
Abbey falling off?
Conclusion
• Mosaic a very useful tool for HEA
• Needs to be part of regular performance
management of contracts
• Addresses some of the data barriers
Measures of need in HEAs
What measure(s) of need and use might be useful in an
HEA of ....
•
•
•
•
•
•
•
general practices in a PCT area
health visitor services
a local flu vaccination programme
services provided by a GUM clinic
services for people with lung cancer
chest pain clinic
Teenage conceptions
What measure(s) of need were used in ....
• any local case study of your own
Some sources of information on variations in need
across different population groups
• estimates from national surveys of comparative levels of need in
different age/gender/ethnic/deprivation groups
– Health Survey for England
– National Psychiatric Morbidity Survey
– British Regional Heart Survey
• local surveys
– Sheffield Health and Illness Prevalence Survey
• modelled prevalence data
– hypertension, CHD, diabetes, COPD, etc
– http://www.apho.org.uk/resource/view.aspx?RID=39389
– synthetic estimates of health-related lifestyle
• NHS data - primary care records, hospital episodes, etc
– is this an appropriate source?
Tensions between reducing inequalities and achieving
equity: how should services change?
• 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?
• tension between achieving equity, ensuring availability to all,
allowing choice, reaching targets
Erewash locality: Use: Need Ratios by Ward
CAS Ward Name
Population
Estimated Smoking
Estimated
No. Fresh Start
Use/Need
Prevalence %
No. Smokers
Users
Ratio
Little Eaton and Breadsall
2954
15.7
464
16
3.45%
Sandiacre North
3493
25.7
898
32
3.56%
Ockbrook And Borrowash
5888
17.8
1048
37
3.53%
Old Park
3218
35.7
1147
46
4.01%
Draycott
3165
21.5
680
29
4.26%
Ilkeston Central
3550
35.4
1257
63
5.01%
Sandiacre South
3532
17.3
612
32
5.23%
Sawley
5368
25.2
1353
76
5.62%
Nottingham Road
5030
28.0
1407
81
5.75%
Derby Road East
3777
29.8
1124
72
6.41%
Long Eaton Central
4825
25.0
1204
77
6.39%
Kirk Hallam
5057
29.0
1468
98
6.68%
West Hallam and Dale Abbey
4121
14.2
587
41
6.99%
Cotmanhay
3494
35.4
1236
88
7.12%
Stanley
1728
20.0
346
27
7.80%
Breaston
3713
14.9
554
48
8.67%
Ilkeston North
3095
36.1
1117
106
9.49%
Little Hallam
3309
17.6
584
81
13.88%
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
Cycle of health equity audit
6
Review progress
and impacts
against targets
5
Secure changes in
investment and
service delivery
1
Agree priorities
and partners
4
Agree local
targets with
partners
2
Equity
profile
3
Identify local
action to tackle
inequalities
The cycle isn’t complete until something CHANGES to reduce inequity
Step 3: Identify effective local action
• 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?
• Step 4: set targets for action
– 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
• Step 5: 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
• Step 6: monitor and review
–
–
–
–
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
Round up
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
Sources of information on Health Equity Audit
HEA Learning from Practice briefing (NICE, 2006)
http://www.nice.org.uk/page.aspx?o=530514
Making the case: HEA (HDA, 2005)
http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/making_the_c
ase_health_equity_audit.jsp
HEA: A guide for the NHS (DoH, 2003)
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@endocuments/dig
italasset/dh_4084139.pdf
HEA: A self assessment tool (DoH, 2004)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_4070715
HEA made simple (HDA/APHO, 2003)
http://www.nice.org.uk/niceMedia/documents/equityauditfinal.pdf
EMPHO http://www.empho.org.uk/Themes/hea/hea.aspx