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Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation
Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation
Background: A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives: To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design: Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results: The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary
management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions: We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of
utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding: The National Institute for Health Research Health Services and Delivery Research programme.
2050-4349
14
National Institute for Health Research
Asthana, Sheena
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Gibson, Alex
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Bailey, Trevor
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Moon, Graham
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Hewson, Paul
00ad18bb-b6e3-4a5c-b0c4-62e1823a22ea
Dibben, Chris
fd69f5d0-e346-4609-84d6-eb2bfcbfa4b7
Asthana, Sheena
e1840442-9c99-4fbb-994c-e9efbd9f6ea6
Gibson, Alex
f2bf89c4-0c0b-4677-a6eb-3978dac873a2
Bailey, Trevor
08b0a229-fbae-4fec-8a4d-675bf7d4ef47
Moon, Graham
68cffc4d-72c1-41e9-b1fa-1570c5f3a0b4
Hewson, Paul
00ad18bb-b6e3-4a5c-b0c4-62e1823a22ea
Dibben, Chris
fd69f5d0-e346-4609-84d6-eb2bfcbfa4b7

Asthana, Sheena, Gibson, Alex, Bailey, Trevor, Moon, Graham, Hewson, Paul and Dibben, Chris (2016) Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation (Health Services and Delivery Research, , (doi:10.3310/hsdr04140), 14, 4) Southampton, GB. National Institute for Health Research 766pp.

Record type: Monograph (Project Report)

Abstract

Background: A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives: To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design: Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results: The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary
management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions: We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of
utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding: The National Institute for Health Research Health Services and Delivery Research programme.

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e-pub ahead of print date: April 2016
Published date: 4 May 2016
Organisations: Faculty of Medicine

Identifiers

Local EPrints ID: 393904
URI: https://eprints.soton.ac.uk/id/eprint/393904
ISSN: 2050-4349
PURE UUID: 38178b7e-5868-43dc-8aab-0371199af5a1
ORCID for Graham Moon: ORCID iD orcid.org/0000-0002-7256-8397

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Date deposited: 09 May 2016 11:23
Last modified: 06 Jun 2018 12:39

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Contributors

Author: Sheena Asthana
Author: Alex Gibson
Author: Trevor Bailey
Author: Graham Moon ORCID iD
Author: Paul Hewson
Author: Chris Dibben

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