1. Confidential unpublished work-in-progress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

2. 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
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Please do not cite any of the findings in this slide pack, as they have not been peer reviewed and are subject to revision as the project proceeds.

3. 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”

4. 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.”

5. 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)

6. 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

7. Methods

8. 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

9. 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

10. 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)

11. 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)

12. 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)

13. 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

14. 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”

15. 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

16. Annual National Monitoring of Equity in the English NHS

17. 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

18. 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.

19. England NHS Equity Performance 2004/5 to 2011/12

21. Annual Local Monitoring of Equity in NHS CCGs for Quality Improvement

22. 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

23. 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

24. 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

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

26. 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

27. Thank you.

28. Spare Slides

30. 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

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