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Ensuring there are sustainable services to promote and protect the public health will be of limited use if – as a result of some oversight or unintentional action – these services exclude some group within society or a specific section of the population. Services need to be sustainable and equitable if they are to be truly effective.

Equity audit is a way of looking at how health services are organised to meet the needs of different people. The aim is twofold:

  • To identify areas of concern where it is apparent that there are differences in health experience and outcome for certain groups as compared to the rest of the population, which may be amenable to intervention; and
  • To recommend practical solutions, where possible, to resolve these issues.

Equity audit is therefore an examination or assessment (audit) of how fairly (equitably) health resources are distributed. It is important to note that equity is not the same thing as equality, since the provision of extra resources may be necessary to make sure some groups have the same capacity to benefit from care as everyone else. An example would be the provision of transport to and from clinic for people with disabilities.

The proces of equity audit

Equity audit considers the delivery of services and people’s experience of them. However, the specific issue under investigation depends upon where on the patient ‘pathway’, from diagnosis through to treatment and outcome, the problem is perceived to be located. The focus may, for example, be on groups that appear to suffer disadvantage due to their inability to access and/or make effective use of services. Alternatively, it may arise as the result of data that highlights apparent inequities, such as higher rates for a particular clinical procedure in some areas, with no obvious explanation.

Equity audit can be described as a six stage process. These are outlined in Box 1.

Principles and priorities

A key principle underpinning equity audit is the need to focus on areas where inequalities are already known or suspected to exist. The priority areas for equity audit in Lothian for the current year are coronary heart disease (CHD), diabetes and breast cancer. These have been selected for a number of reasons, including the following:

  • Data shows that there are disparities between more and less affluent groups in prevalence and health outcomes for diabetes and CHD (Case Study 1);
  • Diabetes is a long-term condition requiring regular review and self-management by patients, and certain groups are less likely to access health services and information to help them manage their condition (Case Study 2); and
  • Breast cancer is the most common type of cancer for women in Scotland and there is lower uptake of screening services by some groups of women.

Recommending interventions designed to address the inequality issues that are identified through equity audit is also an important part of the process. The intervention may not be major in terms of resources (Case Study 3), but it is vital that whatever changes are implemented are followed up and monitored to make sure that the desired effect is achieved.


key points

  • Equity audit assesses how fairly health resource and services are distributed. It focuses on where inequalities are known or suspected, recommends interventions and monitors the resultant impact on service provision.
  • Equity audit plays an important part in addressing health inequalities in Lothian and is a key component in ensuring sustainable services for all Lothian people.
Box 1: The six stages of equity audit

Stage 1 – Agreeing priorities and partners
The first stage involves agreeing the priority areas for investigation, which are selected primarily on the basis that inequalities are already known or suspected to exist. Equally important is the decision about which service providers, both within and outside the NHS, need to be involved, so that ultimately any recommendations for action are made in conjunction and consultation with those who will be part of the implementation.

Stage 2 – Data collection
The information that is used as a basis for identifying issues, and possible ways of addressing them, comes from a variety of sources. These may include: health statistics, such as attendance records, morbidity and mortality data; interviews, both with staff and people who use services; reviews of evidence from studies on similar topics or issues; and information from local agencies and organisations.

Stage 3 – Analysis and recommendations
These different types of information are collated and analysed before recommendations for action are made.

Stage 4 – Agreeing actions
Actions must be agreed with those who will be involved in making the changes.

Stage 5 – Implementation of actions
This is the stage at which the agreed interventions are implemented.

Stage 6 – Monitoring the impact of actions taken
Finally, once implemented, any changes in service provision must be monitored to ensure that the intended result is what actually happens in practice. If it doesn’t, the situation may need to be reviewed.

Case study 1: Diabetes and ‘hard to reach’ groups

In 2007 the Diabetes Managed Clinical Network and the Public Health Directorate carried out an equity audit of diabetes services in Lothian, with specific reference to groups described as ‘hard to reach’. These are people who are likely to face particular barriers in gaining access to and making effective use of health services. The groups considered were:

  • Travelling families;
  • Refugees/asylum seekers;
  • Homeless people; and
  • People with learning disabilities.

Key findings were that service provision needs to be flexible and that the best way to target these groups is through the health professionals who have already established good working relationships with them. Both these points have been taken forward through some changes in service delivery and training on specific diabetes issues with the relevant NHS staff.

Case study 2: Black and minority ethnic people with diabetes

The fact that there is a much higher prevalence of diabetes amongst people who belong to certain minority ethnic groups, in comparison with other groups, is well documented (1). Black and minority ethnic people with diabetes also experience more ill health as a result of their condition and tend to develop Type 2 diabetes at an earlier age than white Scottish people. In 2006 a healthcare needs assessment was carried out by the Directorate of Public Health to look at how well diabetes services met the needs of black and minority ethnic people in Lothian.

The key findings to emerge included the need for:

  • Continuing to raise awareness amongst staff about the prevalence of diabetes in minority ethnic people, and specific issues in relation to the condition for these groups;
  • Ensuring that patients are referred for and receive appropriate education when they are newly diagnosed;
  • Effective systems in place to alert clerical staff to requirements for interpreting services, when necessary; and
  • Improvement of data collection about ethnicity in patient records A subgroup that reports directly to the Lothian Diabetes Services Advisory Group (LDSAG) is working to take forward actions on education and information.

Improvement in recording rates for ethnicity for patients with diabetes has already been significant, with an increase from just under 50% to 98.3% in the few months up until December 2007 (2).

Case study 3: Women with learning disabilities and cervical screening

Concerns about the poor uptake of cervical screening by women with learning disabilities prompted the Healthy Woman Project to seek funding for a research project to explore the possible causes. A survey of general practices was carried out in 2005-06 by the Healthy Woman’s Project with the help of the Public Health Directorate. At the same time there were focus groups with women with learning disabilities themselves and a questionnaire survey of carers. The barriers to accessing screening services that were identified for this group of women led to a number of recommendations for improvement (3).

A key result was the production of a guide for health professionals, which outlines good practice when inviting and screening women with learning disabilities. The guide is supported by a training programme, which is currently being implemented and evaluated in one locality in Edinburgh.