Health equity indicators for the English NHS

Background: There are inequalities in healthcare access and outcomes in the English NHS which raise concerns about both quality of care and justice. In 2012, the NHS was given a statutory duty to consider reducing these inequalities Objectives: To develop indicators of socioeconomic inequality in healthcare access and outcomes at different stages of the patient pathway To develop methods for monitoring local NHS equity performance in tackling socioeconomic healthcare inequalities To produce prototype equity indicators at national and local (clinical commissioning group) level, with appropriate adjustment for need and risk To develop “equity dashboards” for communicating equity indicator findings to decision makers in a clear and concise format Design: Longitudinal whole-population study at small area level Setting: England from 2001/2 to 2011/12 Participants: 32,482 small area neighbourhoods (lower super output areas) of approximately 1,500 people Main outcome measures: Slope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for: (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to healthcare and (8) overall mortality Data sources: Practice level workforce data from the general practice census (Indicator 1), practice level quality and outcomes framework data (Indicator 2), inpatient hospital data from hospital episode statistics (Indicators 3-6), mortality data from ONS (Indicators 6-8) Results: Between 2004/5 and 2011/12, primary care was strengthened and more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time and repeat hospitalisation. Inequality gaps decreased by: 193 patients per family doctor (95% confidence interval 173 to 213), 0.42 preventable hospitalisations per 1,000 people (0.29 to 0.55) and 0.23 amenable deaths per 1,000 people (0.15 to 0.31). In 2011/12, there was little measurable inequality in primary care supply and quality but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to healthcare. Indicators (1) through (5) above found that more than twenty percent of CCGs performed statistically significantly better or worse on equity than the England average in 2011/12 Conclusions: NHS actions can have a measurable impact on socioeconomic inequality in both healthcare access and outcomes. Reducing inequality in healthcare outcomes is more challenging than reducing inequality of access to healthcare. Monitoring of local NHS equity against a national benchmark can now be performed using any administrative geography comprising 100,000 or more people, both to help managers learn quality improvement lessons and to improve public accountability Future work: Exploration of quality improvement lessons from local NHS areas doing better and worse than the national equity benchmark, development of better measures of need and risk and other methodological refinements, and monitoring of other dimensions of equity. Research using these indicators is also needed to evaluate the healthcare equity impacts of interventions and to make international healthcare equity comparisons Funding: The National Institute for Health Research Health Services and Delivery Research Programme