Regional diabetic eye screening (DES) networking day organised by the Midlands and East Screening QA Service (SQAS) team.

1. DESP Networking Day
Health inequalities
March 2nd 2017
Linda Syson-Nibbs
Public Health England leads the NHS Screening Programmes

2. Organisational responsibilities
• The screening quality assurance service ( SQAS ) is responsible for
monitoring the quality of screening services and for promoting continuous
improvement
• NHS England are responsible for commissioning all Section 7a screening
programmes
• NHS are responsible for providing services
• We all have the same legal duties to address equality and health inequalities
• Equality Act 2010 and Health and Social Care Act 2012
• This is reiterated in the NHS Five Year Forward View and NHS England
Public Health Section 7A Commissioning Intentions 2017-18
• Local Government has the same legal duties
DES Networking day

3. Health and Social Care Act 2012
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4. DES Networking day

5. Inequalities mandate
PHE exists to protect and improve the nation's health and
wellbeing, and reduce health inequalities
Operating model for PHE QA Service 2015/16 to 2017/18
contribute to reduction of health inequalities across
screening programmes as measured by reduced
inequalities in coverage and uptake
DES Networking day

6. Health inequalities: what are they and
why do they arise?
Health inequalities are differences between people or groups due to social,
economic , geographical, biological or other factors.
they result in people who are worst off experiencing poorer health and shorter
lives.
The social gradient in heath refers to the fact that inequalities in population
health status are related to inequalities in social status
DES Networking day

7. Determinants of health
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8. DES Networking day

9. Who experiences screening inequalities ?
Published evidence shows that the groups at
greatest risk include ..
• Those experiencing economic deprivation
• Members of minority ethnic groups
• People with learning or physical disabilities
• People with serious and enduring mental
Illnesses
• Other protected groups identified by Equality
Act 2010
DES Networking day

10. Marmot indicators for LAs
http://www.instituteofhealthequity.org/projects/marmot-indicators-2015
DES Networking day
PHOF
http://www.phoutcomes.info/public-health-outcomes-
framework#page/0/gid/1000041/pat/6/par/E12000004/ati/
102/are/E06000015
Local Health
http://www.localhealth.org.uk/#l=en;v=map4

11. What is the difference between
Inequality and Inequity?
• Health inequality describes the differences in health
outcomes between different population groups
according to socio-economic status, geographical area,
age, disability, gender or ethnic group.
• Health inequity describes differences in opportunity for
different population groups which result in unequal
access to health services for example
DES Networking day

12. What can we do next ?
• Little opportunity to impact on wider
determinants of health
• Improving uptake (may improve may worsen)
• Focus on action to reduce inequity (opportunity)
• Proportional universalism
• Audits …
DES Networking day

13. Proportionate Universalism
‘To reduce the steepness of the social gradient in health,
actions must be universal, but with a scale and intensity
that is proportionate to the level of disadvantage’
Marmot Review 2010
DES Networking day

14. Example :Accessible Information Standard
(1)• Legal duty to make reasonable adjustments to avoid
putting a disabled person at a substantial disadvantage
compared with someone who is not disabled
• Includes people who have a disability , mental
impairment or sensory loss
• Does not include a requirement to address language
needs of non English speaking people( but there is still a
requirement to address this under the Equality Act )
DES Networking day

15. Accessible Information Standard(2)
Required to :
1.Identify information or communication needs
(ask people )
2.Record these needs clearly in a set way
3.Highlight or Flag the person’s file or notes
4.Share information about needs with other
providers of NHS and adult social care when
they have consent or permission to do so
5.Take steps to address needs
DES Networking day

16. Example: Programme Standards
Acceptable and achievable coverage and uptake standards
are in place but ,
• Is achievement of achievable standards enough to
address screening inequalities ?
• should new uptake standards be introduced for
vulnerable / under served population groups such those
with learning difficulties , specific ethnic minority groups
populations , certain geographical patches, prisoners
• Do we need a new standard on the collection of ethnicity
or other inequalities data ?
• Other ?
DES Networking day

17. Example :Service specification
Does the specification include sufficient information to enable all
stakeholders to address screening inequities ? for example :
• Are there consistent and specific statements about the need to
address screening inequalities ?
• Are the responsibilities of NHS E commissioners and Trusts clearly
stated : Who should undertake health equity audits ?
• Are under served groups such as people with learning disabilities
specified ?
• Should all specification have an inequalities section ?
• Are health promotion strategies still useful ?
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18. Acknowledgements
• Sean Meehan Health and Well being Programme Lead
• Dr Jo Broadbent East of England Centre Deputy
Director
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19. DESP Networking Day
Health inequalities
Group Work
March 2nd 2017
Public Health England leads the NHS Screening Programmes

20. Vision
To ensure all population groups
have equitable access to
screening services and screening
inequalities are eradicated.
DES Networking day

21. Group Discussion Points
• What activities are already underway to address
screening inequalities ?
• How else could providers, commissioners &
SQAS discharge their inequality duties ?
• Does the current service specification and
standards support our ambitions
• Are there any staff training needs ?
• What are the challenges and how can we
• Address them ?
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22. Action Points in Pairs
• Two examples of activities already
underway
• Two take away actions for your local
team
• Two actions that require wider
engagement for organisers to take away
DES Networking day

23. Bedfordshire Diabetic Eye
Screening Programme
Long-Term Non Attenders
Project 2014

24. Introduction
•During 2014 the BDESP targeted patients that had not
attended a diabetic eye screening test since 2011 or
earlier.
•2,082 patients were identified.

25. Setting the Scene
• 36,133 patients
• Open bookings
• 4 static sites
• 2 mobile cameras
• 1 mobile screening van
• Cover Bedfordshire CCG and Luton CCG
• Uptake Qtr.3 2016/17 – 82.2%

26. Deprivation
• Central Bedfordshire has relatively low levels of
deprivation, ranking 260 out of 326 authorities.
• Bedford Borough is in the mid-range on overall
deprivation, ranking 148 out of 326 local authorities
in England.
• Luton Borough has very high levels of deprivation,
ranking 59 out of 326 local authorities in England.

27. Area
No. of GP
practices
No. of patients
not screened since
2011 or earlier
Percentage
of diabetic
population
Bedford Borough 26 476 5%
Central
Bedfordshire
25 582 5.2%
Luton 30 1024 8.2%
Percentage of Long-Term Non Attenders

28. Methodology
• Patients organised into year of last screened e.g.
2007 and earlier, 2008 etc.
• Patients were telephoned and encouraged to make
an appointment.
• Patients not able to be contacted by phone sent a
fixed appointment.
• On the day of appointment Screener called patient.

29. Outcome
Of the 2,082 long-term non attenders:
• 844 patients were screened
• 720 patients did not attend their fixed / booked
appointment
• 518 patients had already made an apt or status
was ‘excluded’, ‘suspended’ or ‘off register’

30. Referrals
Of the 844 patients screened:
• 28 patients were urgently referred
• 97 patients were routinely referred
In addition, 84 patients were referred into the:
• Hospital Eye Service for non-DR (32 patients)
• SLB clinic (33 patients)
• Digital Surveillance clinic (19 patients)

31. Next Steps
• Email GP practices with their list of non-attenders that
DNA’d their booked / fixed appointment.
• Target patients that have not been screened between
2012 - 2014.
• Target GP practices with uptake below 70% and work
closely with these GP practices in order to increase
uptake.

32. • Obtain intelligence from GP practices with high
levels of uptake.
• Make links with public health colleagues in the local
authorities.
• Establish closer working relationships with the
Integrated Diabetes Community Teams.
• Ensure equal access to patients with a learning
disability.

33. Questions?

34. DNA Telephone Audit
Derbyshire Diabetic Eye Screening Programme
Richard Cragg - Programme Manager

35. Introduction
• At the beginning of 2015 the programme wrote a
business case for a DNA telephone audit and
applied for funding from NHS England.
• The funding was granted by the end of March
2015 for an extra member of staff 2 days a week
(0.4 WTE)
• While recruitment took place the Programme
manager established the goals the audit needed
to achieve, and the method by which this would
be done.

36. The Goals of the Audit
• To speak in person to each patient in a given timeframe that
had DNAd their appointment.
• To record a reason for why the patient did not attend their
appointment (or reasons).
• To take an unbiased view without pre-judgement about why
patients are perceived to DNA.
• Ensure the ‘audit tool’ for gathering the data is granular
enough to record the finer detail of patients answers.
• Analyse the data from the audit and present this in a none
biased pre-conceived way to establish real world results.

37. Method
• The Programme Manager established 31 separate reason codes
grouped into 10 main categories: Patient, Transport, Venue,
Interpreter, Work, Letters, Life Event, Stress, Education, Online
booking issue.
• The audit started in September 2015.
• Naomi started calling patients that had DNAd an appointment in
the previous month (August 2015), and carried on auditing
patients month by month onwards working a month behind. This
ensured that patients gave a credible answer as they could still
remember why they didn't attend.
• Naomi discussed with the patient why they couldn't attend and
recorded any answers they gave against the codes that had been
created.

38. Method contd
• Every patient was given the opportunity to book another
appointment, which was then made by Naomi.
• Naomi informed patients of the Programmes services
and venues, and tried to break down any misconceptions
the patients had which prevented them from attending.
• Every response given by each patient was recorded on
an Excel spreadsheet matrix, which enabled multiple
reasons to be recorded, as well as an outcome to the
phone call (rebooked, hospitalised, no answer etc..)

39. Audit data

40. Data analysis

41. Results
• By a large margin patients forgetting their
appointment was the most frequent reason given
(48%)
• The next most frequent answer given, albeit much
less, was ‘Unwell’ (18%)
• The next single reason given was ‘Family
transport’ (7%)
• Reasons below this % were not considered as
major reasons why patients DNA appointments as
they are close to background statistical ‘noise’

42. Data filter
• To establish whether other factors contributed to
the patients DNA rate, the venues that the DNAs
occurred at were cross-referenced.
• In theory this could establish whether changes in
deprivation across the county had any impact on
the DNA rates.

43. Geographical DNA
data

44. Geographical DNA
Results
• The DNA percentages across the county have a very
small range compared to the Health Deprivation &
Disability scores for the same region (1,094-31,743)
• The highest DNA percentage by geographic spread
was the Royal Derby at 10.08%, and the lowest was
Stanton Day Hospital at Bakewell at 4.51%.
• The average DNA rate was 7.73%, and the range
geographically compared to this average was +30% to
-58% - Statistically a small range that shows no
obvious venue outlier geographically

45. Conclusion
• The 3 most common responses:
• Forgetting the appointment - Common things are
common, and regardless of the diversity of patients,
they all forget.
• Sickness - Again common things are common, and
regardless of diversity all patients have times of
sickness, especially Diabetic patients
• No Friend or Family transport - Many patients rely on
friends and family to bring them to their appointments,
and sometimes they are unable to, so its by no
surprise that this shows up in the data

46. Caveat
• It was acknowledged whilst analysing the data
that it would contain habitual DNA patients that
will never attend without great intervention, and
as such ‘I forgot’ may hide the majority of these.
• 48% is however a large percentage and as such
it was still the overwhelming reason given, and
even if only half were considered to be true it
was still good enough to take action on this.

47. Actions
• Based on this data the Programme wrote
another business case to purchase an SMS text
reminder service.
• The Programme was successful in securing
funding for the SMS text reminder service, and
implemented this in April 2016

48. DNA rates
• The programme has now had the text reminder
service running for 10 months and is tracking the
data.
• Due to the reporting idiosyncrasies in IP
Optomise true DNA rates cannot be established
until one rolling years data is available.
Reporting on shorter timeframes yields poorer
DNA rates.
• Initial results suggests that uptake is improving
as a result of implementing the SMS text
reminder service.

49. Lessons learned
• Try not to over think the reason why things occur - ‘Common
things are common’. The reason why patients DNA is more
likely to be down to what they have alike than what makes
them different.
• Engage with your commissioners for support, help and funding
- Those who don't already will be surprised how forthcoming
they can be for worthwhile well thought out projects.
• Try to resist implementing changes without backing it up with
hard data - A great deal of staffing hours can be wasted on
perceived essential work, but in reality this may only amount to
a small percentage of the overall DNA rate.
• Plan your project first with the right people and knowledge
before embarking on it - Think twice, do once.

50. Acknowledgements• NHS England - East Midlands
commissioning team for funding both
projects and support (Agnes Belencsak,
Sarah Mayfield & Catherine.
• Naomi Goode for calling over 2,000
patients

51. Thank you
for listening

52. Reducing Inequalities
in East & North Herts for patients
with Learning Disabilites and
Dementia
Sue Oliver - Programme Manager
East & North Hertfordshire
Diabetic Eye Screening Programme

53. Patients with a learning disability
Patients with dementia
Equity Audit

54. Screening is one area in which
the health of people with learning
disabilities is being put at risk by
low rates of uptake.
People with learning disabilities
have shorter lives than the
general population

56. LD Champion
Central register of LD patients
Targeted and specific training
Site visits
Record of attendance (DNA, Opt Outs)
Named Nurse

58. Dedicated admin session
Personal contact for LD patients
and carers
Improved uptake

60. Dementia Champion

61. No central register
Limited information from GP’s
Limited training
No named contact

62. IDENTIFICATION

63. TRAINING

64. Adjusted appointment times
Quite waiting areas
Information sharing
Appropriate exclusions

65. EQUITY AUDIT
• An Equity audit is an assessment of the
relationship between inequalities in health
and the distribution of resources for health;
helping us to understand whether the
screening programme is distributing
resources in the best way to reduce
inequalities in uptake and outcomes;

66. AIMS
• Profile the uptake and outcomes of
screening to identify any areas / factors
associated with lower uptake or poor
outcomes
• Consider whether resources are
appropriately distributed to address any
inequalities in uptake/outcomes

67. • 2 GP practices have significantly lower uptake than
average.
• Patients over 65 were less likely to miss an appointment.
• DNA rates were statistically significantly high in those aged
18 to 64, with the highest rates in the 18-24 year olds (33%)
and 24-43 year olds (35%).
• 2 GP practices had DNA proportions significantly higher
than average
• 2 GP practices have significantly higher onward referral
than average

68. SUMMARY
• Inequalities to screening DO exist
• Great initiatives and engaged staff
• More needs to be done
• Complete an Equity Report

69. Thank You
for listening
Any Questions?
su.oliver@nhs.net
01992 823123/823125