Using Equity Audit in NHS Lothian Dr Margaret Douglas Public 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 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 Able to examine demand on the service since Self referral started up in April 2007 The % of Self referrals has increased during the last year and GP referrals is showing a decrease.

Physiotherapy Distribution within SIMD 22,000 cases collected electronically in two physiotherapy centres in Edinburgh CHP Able to examine type of referral – most common GP referral followed by Self referral to Physiotherapy. The analyses focuses on these groups

Physiotherapy - Waits Physiotherapy - Waits Physiotherapy is not subject to the 18 week to treatment target, each centre has there own internal target. This slide examines the wait for routine cases from the date of referral to treatment, measured as the median number of days in each group/quintile. The self group has a slightly longer median wait than the GP group for routine referral, median wait for the GP group is 59 days and 65 for the self group.

Physiotherapy Assessment – Self referral It was also possible to examine the reasons for attendance, this slide shows the self referral group. The main reason group for attending physiotherapy across all the quintiles in the Self group is for joint pain in upper or lower limb, 42% over all. Then about 28% overall in the low back pain group.

Physiotherapy Assessment – GP referral In contrast the next slide shows reasons for attendance on the GP group. The main reason group for attending physiotherapy in the GP group are joint pain in upper or lower limb, at around 29% of all the GP patients in this group, followed by 27% in the low back pain group. and low back pain. An interesting finding in this group are that 10% in the least deprived are attending for a urology matter.

Not Completing Treatment

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 2 Head 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 It took quite a bit of time to get approval from the SCAN board and then this was followed by a delay due to the National report and then Christmas holiday. There was a large amount of data available going back to 1999. Then it turned out that Completeness was an issue as data prior to 2004 didn’t have (2005 in some cases) postcode or gender in the dataset. In the end only 745 cases were used in the analyses out of a possible 1369 cases. Analyses were limited as once you start examine the data by deprivation, age and gender the data quickly becomes prone to small numbers. I am going to show some of the data from the report:

Data completeness N All cases 2002-2008 1085 Missing postcode 332 Missing gender 125 Missing postcode and gender 335 2004-2008 complete 745 Analysis on time referral to treatment: urgent cases 2005-2008 234

H&N Incidence This slide shows the standard Incidence ratios showing each deprivation quintile compared to the most deprived (on the right hand side).

H&N Deaths

Interventions

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