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