Title: Addressing socioeconomic inequalities in healthcare within local areas in England: mixed methods study
Funder: Health Education England

Abstract: Research question How can local areas address socioeconomic inequalities in avoidable emergency admissions? Background There are unfair differences (inequalities25-27) in healthcare in England; poorer access and worse patient outcomes are strongly associated with socioeconomic disadvantage28-30. Excess hospitalisations associated with socioeconomic inequality in England cost the NHS 4.8 billion per year31, much of which is due to avoidable emergency admissions (AEA). In 2015, 263,894 excess AEAs were associated with socioeconomic inequality in England32. Reducing AEAs33-35 through improving coordination of care for people with long-term conditions is a key priority for the NHS36,37. Since the burden of disease sits disproportionately with the most disadvantaged communities, controlling hospital pressures requires addressing inequality issues29,33. The NHS has a legal duty24 to consider reducing these inequalities31 and urgently requires a clearer understanding of how to do this28,29,38.Aims To identify local areas demonstrating consistently reducing or increasing socioeconomic inequalities in AEA To understand why this is the case, identifying factors explaining these variations To help local area decision makers reduce inequalitiesResearch plan An 'explanatory sequential' mixed methods study39 will be undertaken, which aims to explain quantitative findings through subsequent qualitative investigation.In consultation with patients, the public and health professionals, a logic model40-43 will be developed and iteratively refined throughout the research to explain how factors inside and outside of the health and care system may increase, reduce or maintain socioeconomic inequalities in AEA. An equity-focused systematic review44,45 of the determinants of change in socioeconomic inequalities in AEA will be undertaken. Regression analysis of linked routine data will identify local areas demonstrating consistently increasing or reducing socioeconomic inequalities in AEA and explore potential determinants of these trends38. A comparative, in-depth, multi-case study46 of four of these local areas (two increasing, two reducing) will then be undertaken, informed by the review findings and logic model. Evidence will be triangulated from documentary review and up to 60 key informant interviews47 drawing where appropriate upon realist evaluation methods48,49. Expected outcomes Analytic generalisations across all four case studies will deliver working hypotheses about why areas see increasing or reducing socioeconomic inequality in AEA. As well as generating testable hypotheses, this research will also provide methodological learning and a rigorous example of using case-studies to investigate inequality in complex systems50-52. Policy learning about what does and does not work to reduce inequalities will be summarised in a briefing co-designed with patients, members of the public, and health professionals. NHS England and Public Health England plan to share this learning with all local areas across England as part of support they provide to help address inequalities. Impact and benefit The research will help local areas fulfil their legal commitment24 to ensuring services work better together to particularly help those living in disadvantaged communities. This will not only be fairer for patients and the tax-paying public, but by reducing AEA will also reduce pressure on overburdened hospital care, a key priority for the NHS36,37.

Lay abstract: There are unfair differences (inequalities) in healthcare in England. People in poorer neighbourhoods live shorter lives in worse health, with greater need for care. Despite this, they have worse access to, experience of, and outcomes from many types of care. People in poorer neighbourhoods are more likely to have an emergency stay in hospital that could have been avoided (an avoidable emergency admission, AEA). In 2015 there were over 250,000 AEAs linked to living in poorer neighbourhoods in England. Getting health and social care systems working better together to reduce AEAs is a top priority for the NHS. Extra stays in hospital linked to being poorer cost the English NHS 4.8 billion every year. There is an even greater personal cost. No one wants to stay in hospital when this could be avoided. It is unfair this happens more to people in poorer areas. This needs to change and the NHS has a legal duty to consider reducing these unfair differences. Tackling this problem requires actions on a broad scale, with health and social care working with other agencies. In 2016, the NHS launched a measure to show the gap in AEA between people living in rich and poor neighbourhoods. NHS England are promoting the use of this by local areas to see how they compare to each other. However, in doing so they are hampered by a lack of examples of what decision makers in local areas can do to narrow these gaps.My research aims to identify things that can be done to narrow these gaps. I will look to find out what works by comparing local areas where the gap in AEAs is reducing to those where it is increasing. Together with patients, the public and health professionals, I will develop a model to explain how factors, inside and outside of the health and care system, may increase, reduce or maintain unfair differences in AEA over time. I will review previous research to understand what may cause these changes. I will then analyse 9 years of data to find local areas where the gap has been steadily reducing or increasing and what might explain these trends. Based on this, I will select four case study areas to compare and contrast with each other; two where the gap between rich and poor has been reducing and two where it has been increasing. I will interview up to 60 key people, and examine documents produced by the local areas, to understand why they are experiencing the patterns they do. I will extract lessons on what does and does not work to reduce the gap over time. This will add to the model developed initially and provide examples of how unfair differences can be addressed that can be tried in practice.I will co-produce with patients, the public and health professionals a summary of the learning from this research. NHS England and Public Health England plan to share this learning with all local areas across England as part of support they provide to help address unfair differences in health. Thus, my research will help local areas ensure services work better together to particularly help those living in poorer neighbourhoods. This will not only benefit patients, but by reducing AEA will also reduce pressure on overburdened hospital care.Members of the public, patients, and health professionals have helped develop this research such that it is informed by those who will benefit from it. Through regular input to the advisory group, they will continue to be engaged, both in shaping the direction of, and in developing and sharing outputs from, this research.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE