Mind the (health) gap

17 Jan 2023

The role of data and quality improvement in addressing health inequalities.

Dr Josie O’Heney, 2021/22 National Medical Director’s Clinical Fellow, HQIP

As a clinician, the human response is to focus on the problems right in front of you – the patient that has just arrived, the lack of beds or staff to care for people, the crisis in the moment et cetera… However, it is also important for healthcare providers to be aware of data. Unless you understand where there are problems, you can’t work towards solving them. Data informs us about the strategic changes that we need to make to improve care pathways and, importantly, reduce inequalities.

Findings from MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) reports show stark differences in mortality rates amongst women from black-ethnic backgrounds compared to white women. While there has been greater investment in both research and policy changes (with the hope of improving outcomes for disadvantaged groups), we are still a long way from ‘levelling up’. However, without the data to highlight the problem, it is highly unlikely that we would have even started.

The reports mentioned above were produced as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), which is commissioned by HQIP – and this is one of the tools that has been instrumental in identifying health inequalities. The National Child and Mortality Database (NCMD) is another, with its data also highlighting stark inequalities. For example, over a fifth of all child deaths might be avoided if children living in the most deprived areas had the same mortality risk as those living in the least deprived.

To reduce inequalities we need to start thinking smarter

To tackle this issue, NHS England has developed the Core20PLUS5 approach to health inequalities, which focuses on areas where stark inequalities in outcomes have been identified (in maternity, continuity of care for black, Asian and minority ethnic communities and those from the most deprived groups has been prioritised). The PLUS in Core20PLUS5 relates to identifying who in your local population is experiencing poorer than average health access, experience and/or outcomes, and targeting intervention to address it. While most healthcare professionals will have a broad understanding of this issue, it is important to scrutinise local data to really understand it. For example, is a particular population group missing appointments? Then they need to work out why, and target interventions accordingly. In other words, to reduce inequalities we need to start thinking smarter.

The Health Inequalities workspace on the FutureNHS platform is another useful tool. It has excellent resources, including recorded webinars that explain the priority areas in addition to examples of good practice. The Health Inequalities Improvement Dashboard is also helpful, and can support the creation of actionable insights for reducing health inequalities. It enables you to review your data by region and by Integrated Care System (ICS), broken down by ethnicity, age and deprivation – helping you to identify where inequalities exist.

We have always known that inequalities exist, and COVID-19 has shone an even more intense light on them (for example, black and South Asian people were “hit hardest” by the pandemic). So, think of this article as a call to arms for all healthcare colleagues… Think about your clinical area and where the inequalities may lie. Look at your local data, and ensure you are breaking down by ethnicity, deprivation and other protected characteristics. Above all, where inequalities exist, think about why, and what each and every one of us can do to instigate change for the better.

The role of national audits in addressing health inequalities

In 2022, HQIP hosted a series of four online workshops with audit and clinical outcome review programme providers and other guests including patients, NHS England, the Care Quality Commission (CQC), NICE and NHS Digital. We explored collaboratively how we can use our audits and programmes – specifically the National Clinical Audit and Patient Outcomes Programme (NCAPOP) – to identify, measure and address health inequalities. We heard evidence of inequalities revealed by the NCPAOP, for example:

A lower proportion of people of Asian and black ethnicity, as well as those living with deprivation, with type 1 diabetes are prescribed insulin pumps (recommended).
Hypertension prevalence was 3.4 percentage points higher in the most deprived group of the population, compared with the least deprived.
Effective treatment for hypertension was lower in black (63.9%) and mixed-race people (63.6%), compared with Asian (71.7%) and white people (68.2%).

This webinar series identified seven themes:

There is plenty of opportunity for impact – The evidence tells us that there is room for improvement in reducing health inequalities. Data from the NCPAOP can help to identify this, and distinguish between healthcare services.
There is widespread support for the work – The NHS Long Term Plan commits to tackling health inequalities, and all the NCAPOP projects were in support.
Addressing health inequalities is a broad challenge – System-wide developments are required, from data collection and coding, through to analysis and reporting.
We need to tackle the challenge of missing data – Chasing missing data is time-consuming and difficult.
Data quality could be improved – We need to be consistent about what the NCAPOP is collecting and how it is presented, and we need up-to-date information and census data.
Obtaining and using routine data presents challenges – Data and analysis are costly and requires skilled people, so consideration needs to be given to how we might unblock barriers.
We need to support the use of outputs by healthcare services – The data presented needs to be reliable and relevant for local populations, while healthcare services need the capacity to act on the data received.

In summary, these events were an excellent opportunity to work together with our NCAPOP project leads, providers of data and patients in order to focus on supporting the drive to reduce known health inequalities. Together, we can define the patient characteristics that need to be collected and reported on. And we can work with patients and system partners to influence better quality of reporting, and demonstrate the value of this to patients and the NHS.

HEALTH INEQUALITIES: Spotlight on the Early Years. This report from HQIP aims to identify cross-cutting lessons relating to early years healthcare with a focus on health inequalities and variation in care, by reviewing a selection of audit reports from the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Read in full: www.hqip.org.uk/resource/spotlight-on-the-early-years.

This article was originally featured in HQIP’s quality improvement magazine, CORNERSTONE volume 1

When is data the ‘right data’?

17 Jan 2023

Using the right data to support robust healthcare services.

Mirek Skrypak, previously Associate Director for Quality and Development, HQIP

“As I was gearing myself up to write this article about using data to develop robust healthcare services, I took receipt of a rather unusual delivery: A golden microphone with Bluetooth and a voice synthesiser. It proved momentarily inspirational, though how is that relevant, you might ask? Well, it prompted me to think about change and, in particular, how using the right data can support the right change.

On seeing my delivery (which was a present for someone else, by the way), I was struck by how much microphones have changed. I researched early microphones. Although it still performs the same essential function as the original from 1878, my new microphone differs significantly. This golden one with buttons, Bluetooth and charging cable etc shows many visible signs of change, most of which are in response to modern-day needs. Which led me to think about change in healthcare services.

Practice won’t change if you don’t have the right data

The NHS is about 70 years younger than the microphone. Just like the microphone, you could say that it still performs the same function (to improve outcomes for those needing medical care). It also needs to change in order to respond to current need (not least in response to an increasingly ageing population). But how do we ensure that any change implemented is relevant, targeted where it’s needed most, and meaningful to service users? In response, I will share some learning that I think is invaluable in relation to data-informed service design within healthcare…

First, practice won’t change if you don’t have the right data. Whatever tools or techniques you use – whether process improvement, error reduction, waste trimming, agile scrum meetings etc – all of it needs to be done within context. In addition, you need to be curious; you need to ask questions and have ideas. Assuming you have all that, knowing what and how to measure is crucial. Simple right? Well, no! There are a number of variables, models, systems, frameworks and contexts etc that you also need to think about. However, I suggest that there is one other consideration that that is more important than all others: There should be no data without stories and no stories without data. The percentages or figures in charts, tables, recommendations and p values etc are all people. Think about it in terms of this fictional example… Let’s say that there is a national target of 80% for a particular process measure which evidence suggests will improve outcomes. There are circa 170 NHS sites, and let’s assume that 75% are achieving this 80% target for a particular clinical area and pathway. Then, let’s say that, in this pathway, there are 100,000 people who receive this care per year. That means 60,000 patients will achieve the target. But, what about the other 40,000? Suddenly this is not so positive. I know which side – or cohort – I would like to be on as a patient.

There should be no data without stories and no stories without data

So how can we improve these numbers? Here at HQIP, we help service providers to find the right data, to take an effective approach to measuring, and to use that knowledge to build consensus for change. We strongly advocate the synchronisation of Quality Improvement (QI) with national clinical audit and confidential enquiries to enable improvement in outcomes at a national level. Find below what I hope is a useful summary of the key questions that need to be addressed by healthcare leaders and their teams when doing this…

As a manager or clinician:

Have you collected the data in the right way to be able to identify trends?
Do you have the right roles reviewing the data? Who owns it?
Do you know your audience? What is it they need to know?
Are you at risk of decision makers reacting unnecessarily?
How are you presenting your data? Have you presented the data to show a true picture over time?
Is there variation, and is this normal or the result of an exceptional circumstance?
Do you need to consider if it’s actually the system that needs reviewing, or does the target need to change?
Do you need to measure for a longer duration?

As a team or service:

Do we know how good we are?
Do we know where we stand relative to the best?
Over time, where are the gaps in our practice that indicate a need for change ie improvement?
In our efforts to improve, what’s working (and what isn’t)?
Do we know/understand where variation exists in our organisation?
Why are we measuring all this and what difference is this actually going to make to the quality of services?

That’s a lot of food for thought. And I don’t suggest, for one moment, that it’s an easy task. But it is necessary. While I’m not sure that we need a golden, ‘Bluetooth-enabled’ (or the equivalent) healthcare service, we do need to instigate change. I’m convinced – and I wish I had my gold microphone to hand to make this point – that the right data is the way forward in ensuring that those changes are relevant, meaningful and, above all, deliver maximum impact. However, I’m going to give a final word of caution to the renowned statistician David Spiegelhalter, who says: “Signals always come with noise: It is trying to separate out the two that makes the subject interesting.”

This article is one of a number of articles written for CORNERSTONE, HQIP’s free publication, designed to support Quality Improvement. It was featured in the 2023 edition, which features other articles on patient engagement, patient safety, and the importance of health data (among other topics). For more information, go to Healthcare improvement magazine – HQIP.

BLOG Taking the long view: Future-proofing healthcare

15 Dec 2022

Sustainable Respiratory Care Audit Team.
Alice Fitzpatrick, Marsden Rd. Health Centre,
Sustainable Respiratory Care Audit Team.

In June 2022, the Sustainable Respiratory Care project I work with was named winner of the Future-proofing Healthcare category of the 2022 Clinical Audit Heroes awards, as part of HQIP’s Clinical Audit Awareness Week. Of course we were delighted that our work was recognised in this way, but perhaps what was more important was that we would get to raise the profile of the need for sustainable healthcare projects (and share details of our work, into the bargain). Many months have passed since we collected our award but the value of our work continues, and so I am sharing some key highlights in the hope that other professionals will be inspired to ‘take the long view’ and support sustainability in healthcare…

Savings of £8.2 million annually and 58 kilotonnes of carbon dioxide equivalent emissions could be made

In summary, the Sustainable Respiratory Care Audit project provides a structure for the audit of patients’ technique, preferences and knowledge about inhalers as well as the need for clinical review. Selecting appropriate inhaler devices and improving user technique are interventions which can reduce the carbon footprint of healthcare, while improving the quality of care. To improve the control of respiratory conditions and reduce both exacerbations and medicines wastage, it is important to review patients’ inhalers and technique and consider switching a patient’s inhalers where appropriate. It can also provide financial savings.

Commonly used inhalers include Metered Dose Inhalers (MDIs), which contain hydrofluoroalkane (HFA), and Dry Powder Inhalers (DPI) which do not contain HFA. DPIs have a much lower carbon footprint than MDIs; the carbon footprints of MDIs are 10-37 times higher than those of DPIs. While not all patients have sufficient lung function to use a DPI effectively, many patients will receive more effective dosing of inhaled medications using a DPI than using an MDI and prefer not to carry a spacer (MDIs should always be used with a spacer). However researchers have calculated (based on 2017 data) that savings of £8.2 million annually and 58 kilotonnes of carbon dioxide equivalent emissions could be made by replacing just one in ten MDIs in England with the cheapest equivalent DPIs.

More specifically, the audit had a number of key aims. Firstly, to assess whether inhaler technique has been checked regularly and effectively in patients with respiratory disease (as per BTS Asthma Bundle and NICE COPD guidance). Then, it was designed to allow patients to express attitudes and preferences towards inhalers in line with the approach outlined by NICE in their Asthma patient decision aid and the NICE Shared decision-making guidance. Finally, it established a baseline from which to improve the quality and environmental sustainability of respiratory care in the NHS.

So, what did we do in practice? An audit proforma, in the form of a survey that could be carried out with a patient within 10 minutes, was designed by the project team. A data collection spreadsheet was also designed. The proforma was reviewed by respiratory nurses and senior respiratory physicians, piloted on the respiratory ward at Newcastle hospitals, and improved based on patient and health professional feedback. Edits were made – for example, to the information about how to implement the audit, providing exact wording for questions and detailing the need to check with nursing staff about a patient’s cognition and any reasons not to invite a patient to take part before approaching a patient.

The creation of a network of clinicians across the country enabled the collection of national results to which local results could be compared

Next, clinicians from multiple hospitals were recruited using emails sent to professional networks, and introduced to the audit via an introductory webinar. They were provided with the audit proforma and given time and a further webinar in which to propose and discuss any revisions. As a result, minor revisions were made to the wording of questions about patient preferences and inhaler disposal. Clinicians then applied for Caldicott approval and implemented the audit locally.

We are particularly proud of the level of engagement achieved around this project. The creation of a network of clinicians across the country enabled not only collaborative development of an audit proforma, but also the collection of national results to which local results could be compared. The engagement of local teams (which were required to include one senior respiratory clinician and one junior clinician) meant that local solutions to challenges and opportunities for improvement could be identified. Furthermore, the audit engaged patients to give their preferences about their respiratory care and describe their knowledge, to demonstrate how they use their inhaler (thereby auditing patients’ practices, not simply proxies of practice or documentation of others’ practice). This provided information that could inform not only service-wide improvement, but also improvements for individual patients where the need for review or education was identified.

At the time of writing this article, this project is still very much on-going. However, we are already starting to gather some key insights. For example, clinicians found that reviewing patients’ prescriptions highlighted discrepancies between the inhalers that patients were taking and the inhalers prescribed. Importantly, we were able to engage pharmacists in remedying this issue for individual patients, and in considering how to improve practice going forward. The results of the audit will be published once available from all groups, to engage stakeholders in healthcare providers as well as national bodies influencing NHS care. In the meantime, we hope that you agree with the Clinical Audit Heroes award judges that our project demonstrates how incorporating a sustainability perspective in audit can identify opportunities to improve care for individual patients and reduce environmental impacts of healthcare.

Further information: Sustainable Respiratory Care

This project was a collaboration between Dr Sarah Walpole (Newcastle NHS Trust), Dr Lewis Standing (Newcastle NHS Trust), Dr Maria van Hove (University of Exeter), Dr Joseph McElvaney (previously Newcastle NHS Trust, now Greater Glasgow and Clyde) and Dr Anya Gopfert (Northumbria NHS Trust).

BMJ Blog: Collecting data is just the start – Josie O’Heney

2 Jul 2022

“…one day we won’t be reporting that the colour of your skin impacts your risk of dying at what should be one of the happiest times of your life.”

Clinical fellow Dr Josie O’Heney explores health inequalities in maternity in her blog: collecting data is just the start. The blog, written for the BMJ Leader series, is one of five penned by clinical fellows on secondments at NHS England and NHS Improvement and Healthcare Quality Improvement Partnership (HQIP).

Each one explores the ‘5’ focus areas of the CORE20PLUS5 approach, the links between health inequalities and the invaluable contribution of leadership to narrowing the life expectancy inequality gap.

Read the full blog on the BMJ website.