Project Details
Description
Professor Cookson and colleagues at the University of York have developed new indicators of fairness in healthcare, routinely used by NHS England since August 2016. These indicators show how well your local NHS area is succeeding in reducing health inequalities compared to similar local NHS areas. The indicators focus on how far disadvantaged people with long-term health problems are more likely to suffer emergency hospital admissions that could potentially have been avoided. However, it is not known why some areas appear to be getting steadily better at reducing inequality in potentially avoidable emergency admissions, whilst others appear to be getting steadily worse.
This case study project aimed to investigate what may be causing these inequality trends at local level and to learn quality improvement lessons. It focused in-depth on six Clinical Commissioning Group areas using a realist methodology, with a view to learning generalisable quality improvement lessons to assist all areas in improving quality, reducing cost and enhancing fairness throughout the NHS. The purpose of doing this was to produce useful new information for the NHS and to help achieve further impact for the University of York work in developing NHS equity indicators beyond merely altering how the NHS conducts data analysis around health inequalities and towards actually changing how healthcare is delivered and thereby improving patient health outcomes.
This case study project aimed to investigate what may be causing these inequality trends at local level and to learn quality improvement lessons. It focused in-depth on six Clinical Commissioning Group areas using a realist methodology, with a view to learning generalisable quality improvement lessons to assist all areas in improving quality, reducing cost and enhancing fairness throughout the NHS. The purpose of doing this was to produce useful new information for the NHS and to help achieve further impact for the University of York work in developing NHS equity indicators beyond merely altering how the NHS conducts data analysis around health inequalities and towards actually changing how healthcare is delivered and thereby improving patient health outcomes.
Key findings
Our findings have been written up in a full technical report for analysts and academics and a short policy briefing for healthcare decision makers.
The full technical report is entitled: "Reducing Inequalities in Avoidable Emergency Admissions: Case Studies of Six Local Health Systems" and is authored by Julia Knight, John Ford, John Brittain, Chris Bentley, Sarah Sowden, Ana Castro, Tim Doran and Richard Cookson. The team will write this up in a form suitable for publication in an academic journal in due course.
The short policy briefing is entitled: "Briefing to leaders of local NHS healthcare systems on how to reduce inequalities in avoidable emergency admissions". It will be published by NHS England and NHS Health Improvement in due course.
Preliminary findings were presented to health decision makers and stakeholders at one day policy workshops in Bern, Switzerland (15 October 2019) and Skipton House, London (14 November 2019).
The Bern meeting was organised by the Swiss Federal Office for Public Health, who are developing canton-level equity indicators based on the University of York / NHS England approach. The meeting was entitled: "Conference on Equity in Healthcare: Measure, Document, Understand" and included presentations by Kevin Holton, Head of NHS England Equality and Health Inequalities team and Richard Cookson, along with presentations by Swiss academics and policy makers.
The Skipton House meeting was chaired by Kevin Holton and included presentations by Richard Cookson, John Brittain, Julia Knight, John Ford, Chris Bentley and Sarah Sowden. This meeting was entitled: "NHS England and University of York - Inequalities in avoidable ambulatory care sensitive conditions in local health systems project learning event".
Our key findings can be summarised thus:
Key factors perceived by local health officials as potentially contributing to reductions in inequalities were:
Primary care factors:
1.Changes in workforce capacity and capability,
2.Extent of exception reporting and case finding,
3.Programmes of proactive care, and
4.Variations in access and quality of healthcare services in socio-economically deprived areas.
Commissioning factors:
1.Strength of CCG leadership on inequalities,
2.Use of data and incentives to guide decision making, and
3.Targeting of services in more deprived areas to people who had the highest health needs.
There is suggestive before-after evidence that a model of “Focused Care”, delivered in general practices in areas of high deprivation in Oldham CCG, may have reduced emergency secondary care activity and inequalities therein. The Focused Care Programme, created in Oldham in 2010, is believed to have helped improve prevention, health literacy, self-management and community development.
Recommendations:
Whilst the Absolute Gradient Index (AGI) of inequality in avoidable hospital admissions indicator is useful, it only provides a partial picture that can be misleading when reviewing changes in local health inequalities over time and planning healthcare interventions to tackle variations. The researchers suggest complementing this indicator with other measures of healthcare access, patient experience and clinical outcomes when determining local action on health inequalities.
There are no cheap and simple “magic bullet” interventions guaranteed to reduce inequalities in avoidable admissions; instead it is hypothesised that a few sustained, large-scale, multi-component interventions are required that are tailored to specific local population needs and rigorously evaluated will be most effective.
Strengthening primary care in deprived areas, specifically through investing in and assuring adequate workforce, quality, access and continuity alongside ensuring services identify and respond proactively to individuals and communities with the greatest needs is a key recommendation.
Proactive models of care for patients with complex health and social needs should be considered and tailored to local requirements.
Several of the factors identified could be explored further through a range of high quality qualitative and quantitative studies.
Follow-on research is under way, funded by the NIHR and led by Sarah Sowden at Newcastle with support from Professor Cookson and colleagues. UNFAIR: UNderstanding Factors that explain Avoidable hospital admission Inequalities - Research study. Available at: http://bit.ly/UNFAIRstudy
The full technical report is entitled: "Reducing Inequalities in Avoidable Emergency Admissions: Case Studies of Six Local Health Systems" and is authored by Julia Knight, John Ford, John Brittain, Chris Bentley, Sarah Sowden, Ana Castro, Tim Doran and Richard Cookson. The team will write this up in a form suitable for publication in an academic journal in due course.
The short policy briefing is entitled: "Briefing to leaders of local NHS healthcare systems on how to reduce inequalities in avoidable emergency admissions". It will be published by NHS England and NHS Health Improvement in due course.
Preliminary findings were presented to health decision makers and stakeholders at one day policy workshops in Bern, Switzerland (15 October 2019) and Skipton House, London (14 November 2019).
The Bern meeting was organised by the Swiss Federal Office for Public Health, who are developing canton-level equity indicators based on the University of York / NHS England approach. The meeting was entitled: "Conference on Equity in Healthcare: Measure, Document, Understand" and included presentations by Kevin Holton, Head of NHS England Equality and Health Inequalities team and Richard Cookson, along with presentations by Swiss academics and policy makers.
The Skipton House meeting was chaired by Kevin Holton and included presentations by Richard Cookson, John Brittain, Julia Knight, John Ford, Chris Bentley and Sarah Sowden. This meeting was entitled: "NHS England and University of York - Inequalities in avoidable ambulatory care sensitive conditions in local health systems project learning event".
Our key findings can be summarised thus:
Key factors perceived by local health officials as potentially contributing to reductions in inequalities were:
Primary care factors:
1.Changes in workforce capacity and capability,
2.Extent of exception reporting and case finding,
3.Programmes of proactive care, and
4.Variations in access and quality of healthcare services in socio-economically deprived areas.
Commissioning factors:
1.Strength of CCG leadership on inequalities,
2.Use of data and incentives to guide decision making, and
3.Targeting of services in more deprived areas to people who had the highest health needs.
There is suggestive before-after evidence that a model of “Focused Care”, delivered in general practices in areas of high deprivation in Oldham CCG, may have reduced emergency secondary care activity and inequalities therein. The Focused Care Programme, created in Oldham in 2010, is believed to have helped improve prevention, health literacy, self-management and community development.
Recommendations:
Whilst the Absolute Gradient Index (AGI) of inequality in avoidable hospital admissions indicator is useful, it only provides a partial picture that can be misleading when reviewing changes in local health inequalities over time and planning healthcare interventions to tackle variations. The researchers suggest complementing this indicator with other measures of healthcare access, patient experience and clinical outcomes when determining local action on health inequalities.
There are no cheap and simple “magic bullet” interventions guaranteed to reduce inequalities in avoidable admissions; instead it is hypothesised that a few sustained, large-scale, multi-component interventions are required that are tailored to specific local population needs and rigorously evaluated will be most effective.
Strengthening primary care in deprived areas, specifically through investing in and assuring adequate workforce, quality, access and continuity alongside ensuring services identify and respond proactively to individuals and communities with the greatest needs is a key recommendation.
Proactive models of care for patients with complex health and social needs should be considered and tailored to local requirements.
Several of the factors identified could be explored further through a range of high quality qualitative and quantitative studies.
Follow-on research is under way, funded by the NIHR and led by Sarah Sowden at Newcastle with support from Professor Cookson and colleagues. UNFAIR: UNderstanding Factors that explain Avoidable hospital admission Inequalities - Research study. Available at: http://bit.ly/UNFAIRstudy
Status | Finished |
---|---|
Effective start/end date | 30/09/18 → 30/09/19 |