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The ongoing pandemic has, and continues to shine light on inequalities in society.  A recent Health Foundation report, Build Back Fairer: the COVID-19 Marmot Review, provides an in-depth analysis of socioeconomic and heath inequalities in England and highlights how some groups and communities, for example those living in areas of deprivation or Black, Asian, and minority ethnic (BAME) groups, are at a higher risk of contracting and dying from COVID-19. The measures taken to contain the virus also affect less affluent communities more than affluent ones. Such societal inequalities, which existed prior to the epidemic, are a reflection of inequalities in the ‘Social Determinants of Health’; the conditions in which people are born, grow, live, work and age that are shaped by an unequal distribution of money, power and resources. There is also growing evidence of widening inequalities in the ‘quality of care’ received between those most and least deprived through a number of indicators.

There is also growing evidence of widening inequalities in the ‘quality of care’ received between those most and least deprived

Following the initial whole-system response to COVID-19, Scottish Government set out a framework for NHS boards’ remobilisation and recovery that acknowledged the role (albeit limited) that the health service can play in mitigating inequalities. Equality was one of the key guiding principles in this framework.

I work for the Improvement Hub (ihub), part of Healthcare Improvement Scotland. The ihub runs a number of national improvement and service redesign programmes supporting health, social care and housing partners. We also produce a range of toolkits and resources as part of our delivery. In the early stages of the pandemic, we collected learning from the way health and social care services adapted in response to the pandemic as part of our health and social care learning system. We quickly became aware of the uneven impact of COVID-19 through the insights we gathered and our review of the publications. The renewed focus on inequalities in Scotland prompted us to consider how we can further support improvement teams in Boards and our own teams, to consider inequalities as part of quality improvement (QI) work. It was particularly important for us to ensure that our QI work does not increase inequalities by improving the outcomes for some sections of the population but not for others.

We wanted to create a resource to support and encourage QI practitioners to consider inequality as part of the planning and measurement of QI work

We wanted to create a resource to support and encourage QI practitioners to consider inequality as part of the planning and measurement of QI work. In the spirit of QI methodology, we were keen to involve our target audience in the development of the resource. We were cognisant that the resource should draw on published literature but also on the experience of QI practitioners so that it is relevant and meets their needs. We also wanted to explore the level of knowledge and understanding amongst practitioners of the issue of inequalities. We decided to start small: we began searching for relevant resources and published literature and pulled together a draft ‘discussion document’. We then convened an ‘MS teams’ session with practitioners from across the ihub to share the information we gathered, develop shared understanding and create a space for discussion and exchange of ideas and experiences.

Our first session was well received and participants expressed a desire for further opportunities. Many described actions they would take forward. One barrier identified was the availability of data to inform the development of relevant outcomes and balancing measures (hopefully to be addressed by our Public Health Scotland colleagues). There was also an interest amongst practitioners to be involved in more equity-focused QI programmes (such as our planned improvement work to support drug and alcohol services). We are now planning to run further sessions to encourage sharing the learning and ongoing development of the ‘discussion paper’ with a view to creating a community of practitioners interested in the topic who can support others who are less experienced. We hope that this work will support our organisation in achieving its inequalities outcomes.

Our discussion paper, based on our initial review of literature and our workshop, covers the following topics:

  1. Equality and equity in the context of QI
  2. The way QI can effect equity
  3. Inequalities indicators in Scotland and the measurement of inequalities across deprivation categories
  4. Recommendations and examples of measuring reductions in avoidable inequalities
  5. Equity focused QI versus standard QI

We would love to have some feedback and suggestions as to how we can further develop this paper.

Please share your thoughts by getting in touch with the Evidence for Evaluation for Improvement Team, Healthcare Improvement Scotland:  his.inquireseevit@nhs.scot

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