Using Equity Audit in NHS Lothian

Dr Margaret DouglasPublic Health Consultant

Sheila Wilson Senior Health Policy Officer

A whole systems approach to addressing

health inequalities in NHS Lothian

NHS Lothian Principles to address health inequalities

• Broad programme: both health determinants and health services

• Identify and avoid unintended adverse effects of our services• Give priority to disadvantaged groups• Consult with/involve all groups • Interventions coherent, long term, at all levels, with evidence

base• NHS needs to influence partners but also ensure our own work

doesn’t disadvantage vulnerable groups

Whole system approach

• Three strands of work:

• Partnership work to address determinants of inequality

• Ensure mainstream services appropriate for all

• Targeted initiatives

Inequalities in access to healthcare

• ‘Inverse care law’• Physical access eg car ownership• Language barriers• Cultural barriers• Financial barriers• Previous experience• Different expectations

Inequalities in access to healthcare

• NHS by itself cant reduce the inequalities• But we must meet the needs of the people with greatest health

needs• Aim for equal access, equal use and equal quality for equal need • Services may be

– Universal / Targeted / Distributional

Equity audits

• Explore how well existing services meet needs of disadvantaged groups

• Both quantitative data and qualitative methods• Aim to identify changes to improve access and/or outcomes for

disadvantaged groups • Core public health work but with systematic approach and formal

NHS Lothian policy

Selection of topic areas

• Is this a well defined service area? Complexity of patient pathway

• Previous or ongoing work in this service area

• Likely staff support in this service area• Fit with strategic priorities/links with

other workstreams• Is data readily available?• What is the potential impact on health

inequalities?

Example 1:Physiotherapy self referral

• Background: community physiotherapy services and routes of referral

• Aim: to explore differences between GP and self referred patients

Patient Pathway

What are the research questions?

What data could be used?

What dimensions of inequality could the data be broken down by?

Objectives of the equity audit

• To describe self-referrals and other types of referral by age, sex, socioeconomic status and location

• To describe self-referrals and other types of referral by type of discharge (Patient completed treatment, DNA, Did not complete etc.), age, sex, socio-economic status and location

• To describe time from routine referral to start of treatment by type of referral age, sex, socio-economic status and location.

• To describe clinical presentation (back pain etc.) by age, sex, socioeconomic status and location

• To describe type of referral and clinical presentation by ethnic group (where number is sufficient)

Data

• Electronic patient record• Referral date between 1/4/07 and 31/7/10• 20,522 referrals in 2 centres, which account

for about 20% of Edinburgh CHP physio referrals

• SIMD used to derive deprivation quintiles• Onomap software to assign ethnicity

• What are the potential biases in these data?

Physiotherapy - trend

0

10

20

30

40

50

60

Consultant GP MSK Project Other Self

Source of referral

%

200708

200809

200910

Physiotherapy Distribution within SIMD

0

10

20

30

40

50

60

70

80

90

100

5=leastdeprived(n=2040)

4 (n=3891) 3 (n=4408) 2 (n=4237) 1=mostdeprived(n=5355)

Total(n=19931)

SIMD

%

GP SelfConsultant MSK ProjectOther

Physiotherapy - Waits

0

10

20

30

40

50

60

70

80

5=leastdeprived

4 3 2 1=mostdeprived

Total

SIMD

Me

dia

n

GP Self

Physiotherapy - Waits

Physiotherapy Assessment – Self referral

0

10

20

30

40

50

60

70

80

90

100

5 = leastdeprived(n=739)

4 (n=1328) 3 (n=1395) 2 (n=1225) 1 = mostdeprived(n=1593)

Total(n=6280)

SIMD

%

Joint Pain Upper/Low er Limb Low Back Pain Neck PainOther Soft Tissue Upper/Low er Limb Trauma BonyUrology

Physiotherapy Assessment – GP referral

0

10

20

30

40

50

60

70

80

90

100

5 = leastdeprived(n=900)

4 (n=1732) 3 (n=2030) 2 (n=2041) 1 = mostdeprived(n=2560)

Total(n=9263)

SIMD

%

Joint Pain Upper/Low er Limb Low Back Pain Neck Pain

Other Soft Tissue Upper/Low er Limb Trauma BonyUrology

Not Completing Treatment

0

10

20

30

40

50

60

5 = leastdeprived

4 3 2 1 = mostdeprived

Total

SIMD

%

GP Self

Findings

• What do the data tell us?• What questions are not

answered?• What would you like to do next?• What recommendations would

you make?

Example 2Head and neck cancer• Context – Cancer Patient Experience

Service Improvement Programme

• Aim: to explore differences in access and outcome by deprivation, age and gender

Data Source and Issues

• SCAN database• Timing • Data• Completeness• Analyses

Data completeness

N

All cases 2002-2008 1085Missing postcode 332Missing gender 125Missing postcode and gender

335

2004-2008 complete 745Analysis on time referral to treatment: urgent cases 2005-2008

234

H&N Incidence

0

20

40

60

80

100

120

SIMD 5 - leastdeprived

4 3 2 SIMD 1 - mostdeprived*

SIR

H&N Deaths

0

5

10

15

20

25

30

35

40

5= Leastdeprived

4 3 2 1=mostdeprived

Total

Cancer

Other

Interventions

0

10

20

30

40

50

60

70

80

5 = leastdeprived(n=45)

4 (n=47) 3 (n=69) 2 (n=104) 1 = mostdeprived(n=138)

All (n=433)

SIMD 2009

%

Chemotherapy (n=39)

Radiotherapy (n=67)

Surgery (n=206)

Synchronous Chemoradiotherapy (n=55)

other (n=66)

Findings and issues

• What recommendations could you make?

• Communications issues

Criteria for success

• Clear focus and purpose• Engagement and support of service

(including ability and capacity to respond to ongoing queries, willingness to engage with findings)

• Data - availability and quality• Patient pathway with quality indicators• Real issues may be outside NHS

services• More nuanced inequalities may need

qualitative approach