Published: 21/02/2002, Volume II2, No. 5792 Page 22
Equity audit has been flickering beyond the horizon of implementation for years.
It has been commended and recommended by august bodies and documents, including the Acheson report, the NHS plan and the government's recent consultation paper on tackling health inequalities.
What is stopping us getting on with it? First, it has no clear-cut definition, so there is little understanding of how to do it and integrate it into everyday practice. No accountability mechanisms lay down who is responsible for doing it and who should performance-manage it.
And there is no recognition that any audit activity requires time, commitment and resource.
These problems are not insurmountable: clinical audit serves as an instructive comparison. It has a clearly agreed definition and cycle, which includes agreeing further action and audits over time. Such action depends on commitment to further resources for education, training and often service development. Clinical audit is also a prerequisite for effective clinical governance - a legislative requirement - and for continuing education. NHS organisations have at last recognised that audit must be formally timetabled for busy practitioners to participate.
Equity audit needs a clear definition: it might be seen as 'the cycle by which relevant partners review inequities in the causes of ill health and access to effective healthcare and its outcomes for a defined local population, and ensure further action is incorporated into policy, plans and practice'. Equity audit is a public health tool and needs to focus on whole populations.
Like clinical audit, it needs to preserve confidentiality. It has to be seen as a learning process - not simply a new performancemanagement tool.
Equity audit is supported mainly by its champions. The North West can probably claim to have invented it; Liverpool University was responsible for conducting the first formally published equity audit for Chester health authority, and audits in key national priority areas are all under way.
1The thinking behind such audits has been widely shared.
2Slowly, other regional initiatives are developing a methods toolbox for equity audit.
3Elsewhere it is used sporadically and variously - to lobby for more equitable allocation of resources or 'equity profiling' of the population's health. Some have conducted audits, but without considering which inequities to tackle first. Some have tried to commit resources through health improvement programmes or service and financial frameworks without much evidence to support them. All these actions are fragments of the equity audit loop, not the whole cycle.
The Department of Health and Health Development Agency's active interest in developing equity audit tools in the implementation plan to tackle health inequalities is welcome.
This could be accelerated with a small extra national investment in 'equity collaboratives'.
But a good-practice toolbox is not enough on its own. The lessons from clinical audit suggest that we need a clear accountability mechanism to ensure progress. One way would be to make primary care trust public health directors responsible for carrying out such audits triennially with local strategic partnerships, performance-managed by strategic health authorities. It should be a requirement that the findings of such audits are published in the DPH's annual public health reports. This would help SHAs and PCTs keep equity in public health in mind alongside their other objectives.
At a national or regional government level, there is every reason to develop the culture of equity audit, especially as national and regional government action uniquely affects the public health.
Last but not least, there must be recognition - as for clinical audit - that such activities require resources and time.
Because of an equity audIt is complex, multi-agency nature, it must be given priority within existing clinical audit resources, or new resources should be made available. If this is not made possible, we will be left with another good but half-baked idea.
REFERENCES
1Johnstone F, Lucy J, Scott-Samuel A, Whitehead M. Deprivation and Health in North Cheshire: an equity audit of health services.Liverpool Public Health Observatory, EQUAL, Liverpool University, October 1996.
2Johnstone F, Hussey R. Equity Audit - a tool for monitoring community regeneration. Liverpool HA, September 2000. Johnstone F, Hussey R. Paper on equity audit framework.
3Methodologies for Equity audit. In preparation. Eastern Public Health Observatory, personal communication (www. erpho.
org. uk).
Dr Bobbie Jacobson is director of the London Health Observatory.
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