Confidential unpublished work-in-progress A framework for monitoring NHS equity trends: small area analysis of administrative data from 2004/5 to 2011/12 Richard Cookson, Miqdad Asaria, Shehzad Ali September 2015

Acknowledgements Funding: This is work-in-progress independent research funded by the NIHR Health Services and Delivery Research (HSDR) Programme (project number 11/2004/39). The opinions expressed in this slide pack do not reflect those of NIHR, the NHS, or the Department of Health. Project Title: Developing indicators of change in NHS equity performance http://www.nets.nihr.ac.uk/projects/hsdr/11200439 Project Duration: Jan 2013 to Dec 2015 Co-applicants: Richard Cookson (York), Rosalind Raine (UCL), Mauro Laudicella (City), Maria Goddard (York), Brian Ferguson (PHE), Bob Fleetcroft (UEA), Peter Goldblatt (UCL) Core Research Team: Miqdad Asaria, Shehzad Ali, Richard Cookson (York) Please do not cite any of the findings in this slide pack, as they have not been peer reviewed and are subject to revision as the project proceeds.

Benefits to the NHS For the first time, our prototype indicators allow: Annual national monitoring of equity in the English NHS based on socioeconomic inequalities in health care access, quality and outcomes at key stages of the patient pathway Annual local NHS equity comparisons that are useful for transparency and quality improvement Small area analysis yields useful new information about local NHS performance: not just the old story that more deprived areas have poorer health Can compare “clusters” of CCGs with a similar socioeconomic, demographic and/or ethnic mix CCGs performing poorly on equity can learn from similar CCGs performing well within the same “cluster”

Health and Social Care Act 2012 Inequalities Duty – CCGs “14T Duties as to reducing inequalities Each clinical commissioning group must, in the exercise of its functions, have regard to the need to— (a) reduce inequalities between patients with respect to their ability to access health services, and (b) reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services.”

Research Aims To develop a framework for national and local monitoring of equity in healthcare To apply this framework to the English NHS from 2004 to 2011 (a key period of equity-oriented primary care strengthening)

Prototype Indicator Tools Equity Dashboards: 1-page summary Equity Chartpacks: in-depth information in a standard format Equity Google Graphs: create your own graphs At both national and local (CCG) levels Comprehensive suite of visualisation tools to help decision makers and members of the public understand complex inequality patterns

Methods

B. Primary and Community Care Monitoring health care access, quality and outcomes at key stages of the patient pathway A. Home Primary care Supply Primary Care Quality 4. Preventable hospitalisation 5. Repeat hospitalisation 3. Hospital waiting time B. Primary and Community Care C. Hospital 7. Amenable Mortality 6. Dying in hospital D. Death

Indicator Definitions 1. Primary care supply: patients per full time equivalent primary care physiciana,b 2. Primary care quality: average clinical process quality, weighted by expected mortality benefit (based on UK primary care pay-for-performance data) 3. Hospital waiting time: days from outpatient decision-to-treat to inpatient admission-for-treatmentc 4. Preventable hospitalisation: proportion of people with an emergency admission for an ambulatory care sensitive condition (NHS OF 2.3.i list of ACSCs)a 5. Repeat hospitalisation: proportion of inpatients with one or more subsequent any-cause emergency readmission the same yeara 6. Dying in hospital: proportion of people dying in hospital 7. Amenable mortality: proportion of people dying from causes considered amenable to health care (ONS 2012 list of causes as per NHS OF 1a) a 8. Mortality: proportion of people dying from any causea a Adjusted for age and sex each year b Adjusted for neighbourhood ill-health in 2007 c Adjusted for specialty each year

Health Datasets practice level primary care supply from the general practice census (Indicator 1) practice level primary care quality from QOF (Indicator 2) small area level inpatient hospital activity from HES or SUS (Indicators 3-6) small area level mortality from ONS (indicators 6-8)

Population Datasets Small area mid-year population estimates from ONS (all indicators) Practice level small area of residence of all GP-registered patients (“Attribution Data Set GP-Registered Populations”) (Indicators 1 and 2, for attribution from practice level to small area level)

Geography English small areas English large areas 32,482 lower layer super output areas (LSOAs) from the 2001 census Small area neighbourhoods of about 1,500 people (range 1,000 to 3,000) English large areas 211 Clinical Commissioning Groups (CCGs)

Deprivation Index of Multiple Deprivation 2010 overall rank for English small areas Standard indicator used by NHSE and PHE Combines neighbourhood statistics from around 2007 on multiple “domains” of deprivation

Equality Measures Absolute Inequality (Slope Index, SII) The absolute gap between most and least deprived neighbourhoods in England, allowing for the gradient in between Slope of linear regression using all small areas, with deprivation rank on a fractional 0 to 1 scale Relative Inequality (Relative Index, RII) Gap between the most and least deprived neighbourhoods in England as a % of the average A positive index is always “pro-rich”

Age-Sex Standardisation Indirect standardisation based on the year-specific English population Estimate LSOA expected count by applying national age-sex rates to the LSOA population in each age-sex group The adjusted rate is then (observed count / expected count) times the national mean rate This allows the expected age-sex-outcome relationship to change over time e.g. due to changes in average healthcare technology and supply and age cohort effects

Annual National Monitoring of Equity in the English NHS

Equity of Primary Care Supply England 2004/5 Indicator 1: Patients per GP within neighbourhoods (~1,500 people) ranked by deprivation England Average National Inequity Gap

Equity of Primary Care Supply Indicator 1: Patients per GP within neighbourhoods (~1,500 people) ranked by deprivation GP supply increased in all social groups, and the largest increases were in the most deprived areas. Pro-rich inequality gradient eliminated by 2011/12: middle rank neighbourhoods now worst off.

England NHS Equity Performance 2004/5 to 2011/12

Annual Local Monitoring of Equity in NHS CCGs for Quality Improvement

Equity of Primary Care Supply NHS Hull 2004/5 Indicator 1: Patients per GP within neighbourhoods (~1,500 people) ranked by deprivation CCG Average CCG Inequity Gap England Average

Equity of Primary Care Supply NHS Hull 2010/11 Indicator 1: Patients per GP within neighbourhoods (~1,500 people) ranked by deprivation CCG Average No CCG Inequity Gap England Average

Equity Caterpillar Plot Comparing All 211 Clinical Commissioning Groups in England Your CCG CCGs with better than average equity performance GCGs with worse than average equality performance

Association in 2011 between CCG equity performance and CCG deprivation: Preventable Hospitalisation, 2011 2011/12 CCG Equality Performance (lower, better) CCG Deprivation

Summary of Findings Equity in primary care improved 2004-2011 Equity in health care outcomes improved in absolute terms but not in relative terms The equity performance of local CCG areas is not closely associated with deprivation Within “clusters” of similar CCGs, some perform above average and others below average Scope for identifying and sharing good practice

Thank you.

Spare Slides

Trend Measures Two year trend Last two years minus the two years before that Avoids over-reacting to 1 year “data blips” An overall equity trend requires a positive and significant trend in the same direction for both SII and RII

In the local dashboard, a neighbourhood counts as “deprived” if it lies within the most deprived fifth of neighbourhoods in England