Day 7

1. Day 7 Methodologies for Public Health HEA HNA

2. Learning Objectives • To understand what is meant by: • Health Equity Audit • Health Needs Assessment • To understand the drivers behind these methodologies • To increase awareness, through case studies, of how these methodologies are applied in practice • [To discuss the role of public health analysts in these methodologies]

3. Drivers for HEA and HNA • Role of PCTs post-Oct 2006 • Planning Guidance 2005-2008 • HCC organisational health check • Commissioning guidance (?) • Choosing Health Next Steps • Strong and Prosperous Communities (DCLG)

4. PCTs – MAIN ROLES

5. National Standards, Local Action:Health and Social Care Standards and Planning Framework 2005/06–2007/08 Public Health Standards Programmes and services are designed and delivered in collaboration with all relevant organisations and communities to promote, protect and improve the health of the population served and reduce health inequalities between different population groups and areas. PCTs demonstrably improve the health of the community and narrow health inequalities PCTs ensure that the local Director of Public Health’s Annual Report informs policy and practice

6. “The PCT agrees a set of priorities in relation to health improvement and narrowing health inequalities with local authorities and other organisations, which is informed by health needs, health equity audit and public service agreement targets.” “The PCT collects, analyses and makes available information on the current and future health and healthcare needs of the local population.” “The PCT sets planning priorities for disease prevention, health promotion and narrowing health inequalities using information on local population health, including ethnic monitoring, and evidence of effectiveness.”

7. Drivers for HEA and HNA • Role of PCTs post-Oct 2006 • Planning Guidance 2005-2008 • HCC organisational health check • Commissioning guidance (?) • Choosing Health Next Steps • Strong and Prosperous Communities (DCLG)

8. “Strong leadership for health and wellbeing is key. This will be provided by Directors of Adult Social Services, and Directors of Public Health (jointly appointed across health and local government), working alongside Directors of Children's Services. Together they will lead local strategic needs assessments, then plan for the delivery of more effective health and wellbeing outcomes, alongside reductions in local health inequalities”.

10. So in terms of HEA and HNA ... what does a “fit for purpose” PCT look like?

11. Health Equity Audit

12. “HEA is a process for identifying how fairly services or other resources are distributed in relation to the health needs of different groups and areas, and the priority action to provide services relative to need. • The overall aim is not to distribute resources equally but, rather, relative to health need. • The purpose is for health and other services to help narrow health inequalities by taking positive decisions on investment, service planning, commissioning and delivery that narrow inequalities.”

13. what is the difference between health inequality vs. health equity? • Health inequality • Differences in health experience between population groups differing in terms of e.g. geography, age, sex, ethnicity, socio-economic status • Health equity • “Fair” distribution of health/health care resources or opportunities according to population need • “Equal resource for equal need” • Allocating relatively more resources where there is relatively more need e.g. If all PCTs in England have a Coronary Artery Bypass Graft rate of 750 operations per 1,000,000 pop this is equality but is probably not equitable - some PCTs will have a higher level of need.

15. Cycle of health equity audit 1 Agree priorities and partners 2 Equity profile 6 Review progress and impacts against targets 3 Identify local action to tackle inequalities 5 Secure changes in investment and service delivery 4 Agree local targets with partners

16. Cycle of health equity audit 1 Agree priorities and partners 2 Equity profile 6 Review progress and impacts against targets 3 Identify local action to tackle inequalities 5 Secure changes in investment and service delivery 4 Agree local targets with partners

17. coming up next .... • development of HEA and variants on the theme • starting points • case studies, including your own • sources of information on comparative levels of need • tensions between reducing inequalities, achieving equity and the choice agenda

18. Development of HEA (1998-2006) • Acheson (1998) “Independent Inquiry into Inequalities in Health addressing the “inverse care law” • ERPHO (2002) “Introduction to HEA” • APHO/HDA (2003) “HEA Made Simple” • DH (2004) “HEA: a Guide for the NHS” • LHO (2004) “Baseline Survey of PCTs” • HDA/NICE (2005) “Clarifying HIA, IIA, HNA, HEA, REIA” • NICE (2006) “Learning from Practice Briefing”

20. “A Health Equity Audit for Walsall” • scope – very wide • primarily a profile of health inequalities in Walsall • headings from “Tackling Inequalities in Health” - teenage conceptions, smoking in pregnancy, breastfeeding, antenatal and child screening services, child poverty, housing, homelessness, education, smoking prevalence in manual groups, diet, obesity, sport in schools, access to coronary interventions, access to breast and cervical screening, access to sexual health services, influenza vaccination, equity in staffing levels, cancer, circulatory diseases, accidents • summary of current action • recommendations re future action

21. Uptake of aspirin by patients with CHD in Cambridge and Peterborough PCTs • Scope - narrow • Analysis • patients with CHD in Cambridge and Peterborough GP practices • % recorded as having been prescribed/using aspirin • equity between groups • age • sex • PCT • practice • two time periods - 2001 v 2002

22. Uptake of aspirin by patients with CHD in Cambridge and Peterborough Source: ERPHO INphoRM1, Cambs-Peterborough PRIMIS

23. HEA variants • HEA of a single service or resource • focus on fairness of the service • HEA of a whole system (e.g. Walsall) • focus on reducing inequalities in health • enables local partners to prioritise high impact interventions • ... but needs to be be split into a series of single service HEAs (and HNAs) for detailed planning purposes

24. HEA beyond the NHS • are health improvement resources equitably distributed? • examples in Learning from Practice Bulletin • access to leisure centres • access to affordable healthy food • EMPHO Food Access Mapping Seminar

25. Cycle of health equity audit 1 Agree priorities and partners 2 Equity profile 6 Review progress and impacts against targets 3 Identify local action to tackle inequalities 5 Secure changes in investment and service delivery 4 Agree local targets with partners do we have to start at Step 1?

26. Case studies (continued) • HEA in your organisations • case studies from Learning from Practice Briefing • smoking cessation • N.B. EMPHO webpages on HEA being updated

27. Case studies exercise Thinking about your own case studies OR the selected “Learning from Practice Briefing” case studies (Manchester, page 11 or Camden, page 30) • re measures of need: • what was used? • what could have been used? • re follow through to action: • did it happen/is it likely to happen? • if not why not?

28. sources of information on variations in need across different population groups • estimates based on national surveys • Health Survey for England • National Psychiatric Morbidity Survey • British Regional Heart Survey • local surveys • Sheffield Health and Illness Prevalence Survey • Coventry and Brent Diabetes Studies • Health Care Needs Assessment Project • http://hcna.radcliffe-oxford.com/ • information derived from service contacts • ?

29. The Health Care Needs Assessment Project • Source of information on the “epidemiology of indications” • Topics: Alcohol Misuse, Cancer of the Lung, Cataract, Colorectal Cancer, Community Child Health Services, Coronary Heart Disease, Diabetes Mellitus, Dementia, Drug Misuse, Family Planning, Abortion and Fertility Services, Groin Hernia, Lower Respiratory Disease, Benign Prostatic Hyperplasia, Severe Mental Illness, Osteoarthritis, People with Learning Difficulties, Renal Disease, Stroke, Varicose Veins, Accident & Emergency Departments, Child & Adolescent Mental Health, Low Back Pain, Palliative & Terminal Care, Dermatology, Breast Cancer, Genitourinary Medicine Services, Gynaecology, Adult Critical Care, Continence, Dyspepsia, Ethnic Minorities, Health Care in Prisons, Hearing Impairment and Deafnes, Hypertension, Obesity, Pain Services, Peripheral Vascular Disease, Pregnancy and Childbirth, Primary Care Mental Disorders, Severe Challenging Behaviour & Mentally Disordered Offenders http://hcna.radcliffe-oxford.com/

30. tensions between reducing inequalities and achieving equity: how should services change? • should the goal be equal use:need ratios across all cuts of the population? or ... • should services be targeted on sub-groups with the poorest health? • tension between achieving “fairness” of individual services and reducing inequalities in health

32. tensions between reducing inequalities, achieving equity and the choice agenda • “Evidence from the USA suggests that vulnerable patients, including those from black and other minority ethnic groups are increasingly excluded as a result of extending choice. An increase in inequity seems inevitable unless the choice policy includes a means of targeting disadvantaged groups ... to prevent such exclusion.” NHS Service Delivery and Organisation Research & Development Programme, Nov 2006

33. the role of public health analysts in HEA • instigating • designing • analysing • disseminating • follow up

34. Round up • Different models of HEA - macro v micro • Different dimensions of equity - age, gender, ethnicity, social class, area of residence • Creativity may be needed re estimating comparative levels of need • Sophistication/accuracy may not always be necessary • How to act on equity profiling information may not always be clear • How many health equity profiling exercises are followed through to remedial action? • Lessons from Learning from Practice Briefing

35. cataract replacement in Central Derby PCT • predictors of cataract prevalence • primarily age but also ethnicity and deprivation • effective intervention • cataract replacement surgery • map uptake by practice) • highest age-standardised rates in Central Derby practices with the highest Townsend scores and (probably) the highest % ethnic minority patients • need and uptake compared • pattern of uptake looks fairly appropriate - no strong evidence of inverse care law

36. hip replacement rates in Southern Derbyshire • evidence from elsewhere of inequity • predictors of need • age and (possibly) deprivation • effective intervention • hip replacement surgery

37. logical next step is to investigate the “why”

38. hip replacement rates in the East Midlands

39. Case study: smoking cessation services in Southern Derbyshire PCTs Aim: to develop a practical methodology for a health equity profile of smoking cessation services. Q. how fairly is the service configured in relation to the needs of different groups within the population?

40. how fairly is the service configured in relation to the needs of different groups within the population? • how to profile need? • which dimensions of equity • gender, age, ethnicity, social class, area of residence etc • fairness of what? • ?provision • ?uptake • ?outcome

41. Selecting a measure of need • Possible measures • number of smokers • number of smokers wanting to quit • number/rate of smoking-related deaths • socio-economic deprivation • ?other • Selection criteria • how well does it reflect potential to benefit? • can we look at different dimensions of equity? • do we have robust, timely local data? • surveys • primary care • if not, would estimates do?

42. Constructing use:need ratios number of service users/estimated number of smokers .... in each of several cuts of the population differing by • age • gender • electoral ward • PCT • [ethnic group]

46. Ward-level “synthetic estimates” of smoking prevalence • Dept of Health project • Using data from the Health Survey for England • Multivariate modelling to identify social and demographic predictors of smoking • Ward-level estimates based on known social and demographic characteristics of ward populations • Validated against local surveys in London and N.W. England

47. Equity of Uptake by Gender

48. Equity of Uptake by Age

49. Equity of Uptake by Area of Residence

50. Equity of uptake by ethnic group problems experienced: 1. generating prevalence estimates and use:need ratios • published comparative data on smoking prevalence in ethnic groups in England relates to pre-2001 classification system • ethnic monitoring within smoking cessation service is based on post-2001 classification system 2. small numbers in most ethnic groups