The Health Equalities Framework (HEF): An outcomes framework based on the determinants of health inequalities

During 2011 the UK Learning Disability Consultant Nurse Network set about developing an outcomes framework that reflected the wide range of learning disabilities nursing approaches. The need for consistent outcome measures in healthcare services generally, was very much under the spotlight at this time. This sat alongside an acknowledged dearth of standards regarding the provision of learning disability nursing and indeed wider learning disability services with no consistent way of capturing or comparing the impact or outcome of what is provided. The 2010 consultation on the developing NHS outcomes framework highlighted the need to:
“recalibrate the whole of the NHS system so it focuses on what really matters to patients and carers and what we know motivates healthcare professionals - the delivery of better health outcomes”

We now have national outcomes frameworks across Public health, Social Care and the NHS6, all of which have equalities at their heart. The NHS outcomes framework specifically seeks the reduction in premature deaths of people with learning disabilities and there are further consistent themes which emerge across these frameworks:

• Moving away from top down targets to local accountability
• A focus on measuring outcomes
• A drive toward quality improvement
• Improved transparency and accountability

This focus on equality, outcome and accountability inspired our thinking for this work and has been the catalyst to the development of the Health Equalities Framework, or HEF. Our approach has been to develop an outcome measure that builds on the theme of tackling health inequalities, seeing this as the lynchpin to improving health and wellbeing and delivering against the national frameworks.

The Improving Health and Lives Learning Disabilities Public Health Observatory (IHaL) identified five broad determinants of health inequalities for people with learning disabilities:

• Social determinants of poorer health such as poverty, poor housing, unemployment and social disconnectedness
• Physical and mental health problems associated with specific genetic and biological conditions in learning disabilities
• Communication difficulties and reduced health literacy
• Personal health behaviour and lifestyle risks such as diet, sexual health and exercise
• Deficiencies in access to and the quality of healthcare and other service provision.

IHaL have recently provided a further way of structuring the evidence, utilising the following determinant categories: General Socio-Economic, Cultural and Environmental Conditions, Living and Working Conditions, Social & Community Networks, Individual Lifestyle Factors and Constitutional Factors.

However, it is the 2010 and 2011 organising structure that underpins the development of the HEF. The approach focuses on demonstrating reductions in the impact of exposure to these known determinants and thereby reducing the inequalities experienced by people with learning disabilities. By concentrating on the determinants of health inequalities the HEF proactively focuses on prevention and reduction rather than reactive approaches that merely address the symptoms of health inequalities.
Originally conceived as a way of capturing the outcome of learning disability nursing interventions, the model quickly generated interest and engagement from others with an interest in the health and wellbeing of people with learning disabilities - families, commissioners, other professions and people with learning disabilities themselves. In 2012, with support from IHaL and the National Development Team for Inclusion, a working group of commissioners and providers drawn mainly from the South West, but with some representation from other parts of the country, was set up to work alongside the Consultant Nurse group to develop supplementary commissioning guidance, based on the HEF. Consultation, engagement and validation meetings were held with representatives from the National Valuing Families Forum, the National Professional Senate and with local and national representatives of advocacy and service user groups.

The result of these efforts is the Health Equalities Framework and the supporting materials contained herein. The HEF has been developed into an electronic template (or eHEF) with step by step guidance, which organisations and individuals can use to collect and monitor health equality impact data. There is a framework for commissioners and guidance to enable services to be commissioned around health equality. We have also provided a sample Commissioning for Quality and Innovation (CQUIN) template to support commissioners in driving the roll out the HEF across provider organisations. We have included information for families and people with learning disabilities to further support the introduction of the HEF. Reducing health inequalities must be a central aim of all learning disability service provision whatever the setting, approach or needs of recipients. We believe that by monitoring the impact of the known determinants of health inequalities there is the opportunity to consistently and reliably demonstrate the difference that support from services is making to the health and wellbeing of people with learning disabilities of all ages, whether they are profoundly disabled, physically or mentally unwell, in hospital or living in the community.

The HEF is not intended to replace existing outcome tools that are used in specific settings or for specific interventions; its purpose is to provide a clear and transparent overarching health-focused outcomes framework with a common language which can aid understanding for everyone involved, particularly between commissioning and service provision and across health and social care settings.

The aim has been to provide a tool which makes sense to everyone, that is sensitive to outcomes at an individual level and which allows aggregation of data in order that population trends at different levels can be better understood. We hope you find it useful and that it contributes to a wider understanding of health inequalities amongst people with learning disabilities, highlighting and evidencing the approaches that make a real and positive difference.