Incorporating Equity Into Health Care Performance Measurement: A Framework And Application

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Speaker: Richard Cookson

Date/Time: May 8, 10 AM – 12 PM

Link to Presentation Slides: Incorporating Equity Into Health Care Performance Measurement

Room: HS 618 (Health Sciences Building, 155 College Street)


Background: Equity is an important policy objective, yet remains isolated from mainstream health care performance measurement. National and local health care policy makers lack routine data to help them monitor the impact of their decisions on health inequalities.

Objectives: This study develops a population health framework for incorporating equity into health care performance measurement, and applies it to England from 2001 to 2011 during a period of accelerated health care expenditure growth and health system reform.

Methods: The framework integrates the measurement of average and equity performance across all main stages of the patient pathway, aligning health care objectives with the two population health objectives of improving average health and reducing health inequality. It also facilitates detailed local performance monitoring of sub-national administrative areas on a comparable basis. The application is based on nine performance indicators constructed using a data infrastructure combining primary care, hospital, mortality, population and area deprivation data for the whole of England at small area level (32,482 neighbourhoods of about 1,500 people) from 2001 to 2011. Average performance was measured using population means, and equity performance using regression-based slope and relative indices of inequality that can be interpreted as absolute and proportional gaps between the most and least deprived neighbourhoods in England. National and local “dashboards” were developed to communicate findings to decision makers in a one-page format, along with standardised “chartpacks” and flexible “google graphs” to provide in-depth data visualisation.

Preliminary Findings: Average performance improved on almost all indicators between 2001 and 2011. There were also significant reductions in inequality in full time equivalent primary care physicians per 100,000 need-weighted population and in primary care quality as measured by clinical process indicators in the UK pay for performance programme. However, after adjustment for age and sex (but not yet morbidity) inequality widened in preventable hospitalization, 12-month post-hospital mortality and mortality amenable to health care. Inequality in overall mortality and morbidity also widened. Sub-national equity performance is not closely correlated with sub-national area deprivation.

Discussion: By linking national administrative datasets at small area level, it is possible to integrate equity into health care performance measurement at both national and sub-national levels within a population health framework. Our application to England suggests that average performance improved during the 2000s, along with equity in primary care supply and clinical process quality, while equity in health care outcomes may have deteriorated. However, we have not yet controlled for morbidity and so it is not yet clear how far widening inequality in health care outcomes is due to social determinants of health beyond health care.


Richard’s research focuses on equity in health and health care, and he is conducting a five-year fellowship research programme on health equity impacts. Richard is a member of the NHS Outcomes Framework Technical Advisory Group (OFTAG). He served on the National Institute for Health and Clinical Excellence (NICE) Technology Appraisal Committee from 2002-7 and the Public Health Interventions Advisory Committee from 2007-9, and was seconded to the Prime Minister’s Delivery Unit in the Treasury in 2010. He helped set up the UK Health Equity Network in 1999, and co-chaired the economics sub-group for the Marmot review of health inequality in Europe from 2010-12. He edited the public health section of the Elsevier On-Line Encyclopedia of Health Economics from 2012-14, and from 2011-13 edited the collected works of Tony Culyer and Jonathan Bradshaw and published them in free e-book editions. He also writes the occasional blog about health economic issues.


This is unpublished work-in-progress arising from the research project: Cookson, R, Raine, R, Laudicella, M, Goddard, M, Ferguson, B, Fleetcroft, R, Goldblatt, P. Jan 2013 to Dec 2015. Developing indicators of change in NHS equity performance. NIHR Health Services and Delivery Research (HSDR) Programme (project number 11/2004/39). Please do not cite this work, as it is work in progress and subject to change and revision as the project proceeds.

For helpful comments the authors would like to thank Allan Baker, Chris Bentley, Tim Doran, Mark Dusheiko, Donald Franklin, Chris Gale, Nils Gutacker, Hugh Gravelle, Ann Griffin, Iona Heath, Azim Lakhani, Alan Maynard, Nick Mays, Lara McClure, Mark Petticrew, Jennie Popay, Carol Propper, Rita Santos, Peter Smith and Wim Troch. We would also like to thank Ruth Helstrip for helping to organise the public consultation work that informed the indicator selection process, and the members of the public who participated in our “citizens’ panel” meetings and on-line survey. Data were provided under license from the Department of Health (GMS and ADS), the Health and Social Care Information Centre (HES), and the Office of National Statistics (mortality). We would also like to thank Tim Doran for providing publicly available QOF data in a pre-assembled format. The views expressed in this abstract are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or any of the data providing organisations.