Strengthening Equity in NHS Resource Allocation Pauline Craig, Head of Population Health, Health Scotland Karen Facey, Independent Consultant Lynne Jarvis, Principal Information Analyst, PHI, NSS

Outline Innovative application of HIIA tool: Acute MLC review of the NHS Resource Allocation Formula Aim towards equitable healthcare: proportionate universalism for populations with greatest need Describe the MLC review and the HIIA process Results, recommendations and reflections

TAGRA Acute Morbidity & Life Circumstances (MLC) Subgroup The NHSScotland Resource Allocation Committee (NRAC) formula informs funding allocation to the 14 territorial NHS Boards for Hospital and Community services and GP Prescribing ( 70% of NHSScotland’s budget) The Technical Advisory Group on Resource Allocation (TAGRA) maintains and develops the formula. The Acute Morbidity and Life Circumstances (MLC) review is part of a rolling programme of review Acute care programme allocates £4.5bn, 52.4% of the total £8.5 billion allocated via the NRAC formula for the year 2016/17 Review aimed to improve the formula’s ability to allocate funds between the territorial NHS Boards on a fair and equitable basis Review took place between Feb 2014 and July 2016

Focus for the review The MLC adjustment takes account of additional needs over and above those based on age and sex Areas with greater levels of ill health, or where residents subject to life circumstances that result in greater ill health, will incur higher health board costs Adjustment calculated by identifying factors that explain the variation in actual costs of healthcare between small areas for each care programme, using statistical regression analysis Review analyses included costing method, model spec (incl. geography, diagnostic groups, age split), needs index, additional variables (eg prisoners, urban-rural), unmet need, HIIA

Health Inequalities Impact Assessment (HIIA) Systematic consideration of the ways a policy might affect people differently in order to inform the policy’s development and implementation. Integrated approach to impact assessment drawing on methodology from Health Impact Assessment, Equality Impact Assessment and Human Rights Impact Assessment. Encourages consideration of the intersections of different potential impacts on individuals and communities. Developed following a recommendation in Equally Well, piloted in 2010 with NHS Boards and the Scottish Government, still in use. A narrow focus on one aspect of an individual´s or a group´s identity may work hinder understanding and responding to the reality of people’s lives and experiences. The HIIA approach has been used with policy and service development in Scottish Government, local and national Health Boards and some third sector agencies, since its launch in November 2011

National drivers and benefits of impact assessment Legal Meets legal duties and challenges discrimination and a ‘one size fits all’ approach Business Risk mitigation Quality improvement Moral Works to reduce health inequalities for those facing multiple disadvantage, taking a human rights based approach Clinical Strategy (2016) 2020 Vision (2013) SNAP for HR (2013) Patients Rights Act (2011) Equality Act (2010) Quality Strategy (2010) Equally Well (2008) Human Rights Act (1998) Trainer prompt: Can you think of any other benefits

The HIIA process

Small population group snapshot (2011) Minority ethnic and white non-British groups make up 8% of the Scottish population (minority ethnic alone 4% Scotland cf 15% in England) 49,000 people of Pakistani origin; 4,000 Bangladeshi and 4,000 Gypsy/Travellers 8,000 prisoners 41,500 assessed as homeless; 55,500 applied 41% of BSL speakers have long term disability or illness; 17% Punjabi speakers; 30% Scots

Ethnic Inequalities in Health for Scottish Women (similar picture for men) Which ethnic groups have the poorest health?

Three types of evidence use in HIIA Aspiration – encourage people to draw on all 3 types in an impact assessment

Integrating HIIA with the NRAC acute MLC sub group Core criteria review Equity: how are all ‘variations in need’ across the country understood and gaps being addressed, beyond age, geography and rurality? Transparency: describing the systematic consideration of inequality and findings

Acute MLC review HIIA HIIA embedded throughout the review with three components: Equality advisor as member of subgroup 2. Focussed HIIA workshop discussion at the midpoint Process of agreeing recommendations for equity-related variables following further analyses.

Results of the HIIA Equity principle for TAGRA expanded The primary consideration should be to achieve the greatest possible accuracy in capturing the cost implications of variations in need between population groups and across the country, in order to develop a formula that delivers the greatest possible equity of access to health services.

Results for each component Component 1: identification of new potential variables for the model – of which life expectancy was considered but rejected, and DNA rates reached the final candidate list then rejected due to the potential for creating a perverse incentive for Boards as a supply variable Component 2: additional equality advisers attended the mid-review workshop, identifying ethnicity and unpaid care as candidate variables. Unpaid care rejected due to the absence of a dose-response relationship between unpaid care provision and higher acute costs; ethnicity subject to many analyses but eventually rejected as the complexity and depth of need could not be captured in a way that would remain stable over time. In addition, could not show a level of impact that would require adjustment to the formula. Component 3: consensus on recommendations from the HIIA process. Eg ethnicity was fully explored and debated before agreeing to reject.

Recommendations from the HIIA Unpaid care and ethnicity should be re-examined in later reviews if better ways of capturing need could be developed Need for other ways to think about proportionate health care provision for small groups, eg through the High Resource Individuals initiative or through the Scottish Allocation Formula (SAF) for GP practices No changes to the formula but a commitment to analysing the formulas impact on equity in acute healthcare with multiple opportunities to consider equality, inequality and human rights The whole subgroup and review team were involved in the HIIA throughout: the principle of equity was embedded

Reflection Embeddedness resulted in ownership across the whole subgroup, not just with an equality advisor Transparency of considerations: rationales for including, analysing and rejecting variables were debated, agreed and recorded Small population groups were visible in the planning Local profiles and experiential knowledge remain the main data sources for identifying and meeting needs of small population groups but potential for different levels of commitment and therefore inequity. Is there more to do on national scale? Principles of equity and transparency clearly worked through.

http://www. tagra. scot. nhs http://www.tagra.scot.nhs.uk/subgroups/morbidity-and-life-circumstances/ http://www.healthscotland.com/equalities/hiia/index.aspx Which ethnic groups have the poorest health? Scottish Government stats http://www.gov.scot/Resource/0048/00484303.pdf