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Day 7 Methodologies for Public Health HEA HNA Slide 2 Learning Objectives 1.To understand what is meant by: Health Equity Audit Health Needs Assessment 2.To understand the drivers behind these methodologies 3.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] Slide 3 Drivers for HEA and HNA 1.Role of PCTs post-Oct 2006 2.Planning Guidance 2005-2008 3.HCC organisational health check 4.Commissioning guidance (?) 5.Choosing Health Next Steps 6.Strong and Prosperous Communities (DCLG) Slide 4 FunctionsRoles Engaging with its local population to improve health and well-being (i)Improving health status of its population, and reducing health inequalities, in partnership with LAs (ii)Contributing to well-being and sustainable community development, in partnership with LAs (iii)Protecting health including through a robust system of emergency planning Commissioning a comprehensive and equitable range* of high quality,responsive and efficient services, within allocated resources *(across all service sectors: public health, all types of primary care services including dentistry pharmacy and optometry, community health services, social care, mental health, electives, urgent care etc) The PCT primarily performs its commissioning function, for example in relation to acute services, through empowering, supporting and coordinating a comprehensive system of practice-based commissioners; who in turn are responsible for the care for their registered patients. Responsibility for commissioning primary medical services is not devolved to practices but fully retained at PCT level. Where appropriate, services are commissioned jointly with local authorities. Specialised services will be commissioned collaboratively with other PCTs (or nationally) in line with the findings of the forthcoming review by Sir David Carter due later in 2006. The PCT should underpin all aspects of commissioning with excellent and timely information and analysis. The five key commissioning roles are: 1.Assessing needs, reviewing provision & deciding priorities: assessing the needs of its population, gaining an excellent understanding of its expectations and wishes; mapping these against an evaluation of current service provision, including an assessment of the structure of supply and the ability of patients to choose; deciding its local priorities for developing and transforming services 2.Designing services: in partnership with practice-based commissioners, specifying the range, nature and quality of services to be provided along different patient pathways, in line with the White Paper Our Health, Our Care, Our Say; drawing on evidence of cost-effectiveness and best practice; enabling provider innovation; and reflecting expected capacity requirements 3.Shaping the structure of supply through stimulating provider interest, deciding when to go to tender, and by placing contracts. The aims being (a) to promote patient choice and competition between providers - and where not that is not possible, to maximise contestability for supply; and (b) to ensure services are joined-up for patients along pathways, through providers working in partnership. In discharging this aspect of commissioning, the PCT works closely with relevant SHAs and other PCTs 4.Managing demand for services and living within its cash-limited allocation of resources, particularly through a comprehensive system of practice-based commissioners 5.Performance-managing providers through contracts and wider relationships, to ensure contract requirements are met eg on national targets, quality and equity of access; and taking systematic account of patient and practice feedback. The PCT also regulates primary care performers. Directly providing high quality responsive and efficient services where this gives best-value Directly providing primary and community-based services (and for Care Trusts, adult social services), where the PCT s commissioning function shows that direct provision of such services is best for patients and also provides best value for money for taxpayers. The PCT provider function must be clearly separated from the PCT commissioning function from Board-level down; the latter holds the former to account for delivery. The PCT also develops primary care contractors. PCTs MAIN ROLES Slide 5 National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/062007/08 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 Slide 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. Slide 7 Drivers for HEA and HNA 1.Role of PCTs post-Oct 2006 2.Planning Guidance 2005-2008 3.HCC organisational health check 4.Commissioning guidance (?) 5.Choosing Health Next Steps 6.Strong and Prosperous Communities (DCLG) Slide 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. Slide 9 Slide 10 So in terms of HEA and HNA... what does a fit for purpose PCT look like? Slide 11 Health Equity Audit Slide 12 1.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. 2.The overall aim is not to distribute resources equally but, rather, relative to health need. 3.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. Slide 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. Slide 14 Slide 15 Cycle of health equity audit 1 Agree priorities and partners 3 Identify local action to tackle inequalities 4 Agree local targets with partners 5 Secure changes in investment and service delivery 6 Review progress and impacts against targets 2 Equity profile Slide 16 Cycle of health equity audit 1 Agree priorities and partners 3 Identify local action to tackle inequalities 4 Agree local targets with partners 5 Secure changes in investment and service delivery 6 Review progress and impacts against targets 2 Equity profile Slide 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 Slide 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 Slide 19 Slide 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 Slide 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 Slide 22 Uptake of aspirin by patients with CHD in Cambridge and Peterborough Source: ERPHO INphoRM1, Cambs-Peterborough PRIMIS Slide 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 Slide 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 Slide 25 Cycle of health equity audit 1 Agree priorities and partners 3 Identify local action to tackle inequalities 4 Agree local targets with partners 5 Secure changes in investment and service delivery 6 Review progress and impacts against targets 2 Equity profile do we have to start at Step 1? Slide 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 Slide 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) 1.re measures of need: what was used? what could have been used? 2.re follow through to action: did it happen/is it likely to happen? if not why not? Slide 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 ? Slide 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/ Slide 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 Slide 31 Table 4. Erewash PCT: Use: Need Ratios by CAS Ward CAS Ward NamePopulationEstimated SmokingEstimatedNo. Fresh StartUse/Need Prevalence %No. SmokersUsersRatio Little Eaton and Breadsall295415.7464163.45% Sandiacre North349325.7898323.56% Ockbrook And Borrowash588817.81048373.53% Old Park321835.71147464.01% Draycott316521.5680294.26% Ilkeston Central355035.41257635.01% Sandiacre South353217.3612325.23% Sawley536825.21353765.62% Nottingham Road503028.01407815.75% Derby Road East377729.81124726.41% Long Eaton Central482525.01204776.39% Kirk Hallam505729.01468986.68% West Hallam and Dale Abbey412114.2587416.99% Cotmanhay349435.41236887.12% Stanley172820.0346277.80% Breaston371314.9554488.67% Ilkeston North309536.111171069.49% Little Hallam330917.65848113.88% Slide 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 Slide 33 the role of public health analysts in HEA instigating designing analysing disseminating follow up Slide 34 Round up 1.Different models of HEA - macro v micro 2.Different dimensions of equity - age, gender, ethnicity, social class, area of residence 3.Creativity may be needed re estimating comparative levels of need 4.Sophistication/accuracy may not always be necessary 5.How to act on equity profiling information may not always be clear 6.How many health equity profiling exercises are followed through to remedial action? 7.Lessons from Learning from Practice Briefing Slide 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 Slide 36 hip replacement rates in Southern Derbyshire evidence from elsewhere of inequity predictors of need age and (possibly) deprivation effective intervention hip replacement surgery Slide 37 logical next step is to investigate the why Slide 38 hip replacement rates in the East Midlands Slide 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? Slide 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 Slide 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? Slide 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] Slide 43 Table 1. Erewash PCT: Use:Need Ratios by Gender Adults 16+ Est.Smoking Prevalence % Estimated No.No. Fresh StartUse:Need SmokersUsersRatio Male4264727125235294.22% Female4559326121487686.32% Slide 44 Table 2. Erewash PCT: Use: Need Ratios by Age (Men) Age group Male Est.Smoking Prevalence % Estimated No.No. Fresh StartUse/Need Adults 16+SmokersUsersRatio 16 - 24536436%1931201.04% 25 - 34745038%2831702.47% 35 - 44855034%29071143.92% 45 - 54725230%21761175.38% 55 - 64660024%15841157.26% 65 - 74438418%789749.38% 75+304710%305123.94% Table 3. Erewash PCT: Use: Need Ratios by Age (Women) Age group Female Est.Smoking Prevalence % Estimated No.No. Fresh StartUse/Need Adults 16+SmokersUsersRatio 16 - 24525736%1893824.33% 25 - 34789635%27641535.54% 35 - 44863430%25901485.71% 45 - 54722228%20221376.77% 55 - 64640323%14731459.85% 65 - 74486418%876637.20% 75+531710%532173.20% Slide 45 Table 4. Erewash PCT: Use: Need Ratios by CAS Ward CAS Ward NamePopulationEstimated SmokingEstimatedNo. Fresh StartUse/Need Prevalence %No. SmokersUsersRatio Little Eaton and Breadsall295415.7464163.45% Sandiacre North349325.7898323.56% Ockbrook And Borrowash588817.81048373.53% Old Park321835.71147464.01% Draycott316521.5680294.26% Ilkeston Central355035.41257635.01% Sandiacre South353217.3612325.23% Sawley536825.21353765.62% Nottingham Road503028.01407815.75% Derby Road East377729.81124726.41% Long Eaton Central482525.01204776.39% Kirk Hallam505729.01468986.68% West Hallam and Dale Abbey412114.2587416.99% Cotmanhay349435.41236887.12% Stanley172820.0346277.80% Breaston371314.9554488.67% Ilkeston North309536.111171069.49% Little Hallam330917.65848113.88% Slide 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 Slide 47 Equity of Uptake by Gender Slide 48 Equity of Uptake by Age Slide 49 Equity of Uptake by Area of Residence Slide 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 Slide 51 Response from service managers & commissioners Early conclusions: Local service managers/commissioners engaged Gross inequities identified Sophistication and high degree of accuracy unnecessary Real local data on need unnecessary Credible estimates acceptable Will service provision change?