1. Using Equity Audit in NHS Lothian
Dr Margaret Douglas
Public Health Consultant
Sheila Wilson
Senior Health Policy Officer

2. A whole systems approach to addressing health inequalities in NHS Lothian

3. 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

4. Whole system approach Three strands of work:
Partnership work to address determinants of inequality
Ensure mainstream services appropriate for all
Targeted initiatives

5. Inequalities in access to healthcare
‘Inverse care law’
Physical access eg car ownership
Language barriers
Cultural barriers
Financial barriers
Previous experience
Different expectations

6. 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

7. 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

8. 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?

9. Example 1:Physiotherapy self referral
Background: community physiotherapy services and routes of referral
Aim: to explore differences between GP and self referred patients

10. Patient Pathway

11. 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?

12. 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)

13. 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?

14. 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.

15. 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

16. 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.

17. 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.

18. 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.

19. Not Completing Treatment

20. Findings What do the data tell us? What questions are not answered?
What would you like to do next?
What recommendations would you make?

21. 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

22. 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:

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

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

25. H&N Deaths

26. Interventions

27. Findings and issues What recommendations could you make?
Communications issues

28. 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