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 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

15. Physiotherapy Distribution within SIMD

16. Physiotherapy - Waits

17. Physiotherapy Assessment – Self referral

18. Physiotherapy Assessment – GP referral

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

23. Data completeness N All cases 2002-20081085 Missing postcode332 Missing gender125 Missing postcode and gender 335 2004-2008 complete745 Analysis on time referral to treatment: urgent cases 2005-2008 234

24. H&N Incidence

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