CEMENTO

Small Area Geography: The basic small area geographical unit provided in the datasets used was the 2001 “lower super output area” (LSOA). There are 32,482 of these small area

neighbourhoods in England, defined by the 2001 census to cover approximately 1,500 people each (minimum 1,000 and maximum 3,000). LSOA boundary definitions were updated following the 2011 census, resulting in 32,844 small area neighbourhoods. These new 2011 LSOAs form the basic building blocks of the higher level geographies that we aggregate our results to, such as clinical commissioning groups. LSOA level indicator production and adjustment is conducted at 2001 LSOA level, and the results are then mapped onto 2011 LSOAs for production of equity measures at national and CCG levels. The mapping between the 2001 and 2011 LSOAs is discussed below in part (ii) of this methods chapter.

Small Area Deprivation - We measured the socioeconomic status of each 2001 LSOA neighbourhood using the index of multiple deprivation (IMD). This is a widely used measure that combines a wide range of data sources on multiple aspects of social deprivation. Seven indicator domains are combined into a single deprivation score for each small area. The indicator domains comprise “income deprivation,” “employment deprivation,” “health deprivation and disability,” “education, skills, and training deprivation,” “barriers to housing and services,” “living environment deprivation,” and “crime.” Each neighbourhood is ranked relative to one another according to their level of deprivation. Although in theory there is an

element of circularity in including the “health deprivation and disability” domain, in practice the exclusion of this domain makes little difference since this domain is only one small element of the overall index and the domains are all highly correlated. We used the version of IMD published in 2010, which contains data mostly relating to the year 2007 in the middle of our analysis period.47 We used the most informative IMD 2010 index available: overall deprivation rank for all 32,482 LSOAs in 2001. We used the same deprivation index for all years to ensure that our findings reflected real changes in health care delivery and outcomes, rather than artificial changes in the calculation of the deprivation index or the composition of neighbourhoods. This does raise the issue, however, of how accurately the deprivation of a neighbourhood in 2007 reflects its deprivation in 2001/2 and 2011/12. To assess this, we looked at cross tabulations of change over the seven year period between IMD 2004 (data for 2001) and IMD 2010 (data for 2007). These show that 84% of LSOAs in the most deprived fifth remained in the most deprived fifth, that 88% of neighbourhoods in the least deprived fifth remained in the least deprived fifth, and that only 14% of LSOAs changed rank by the equivalent of one quintile group or more.

Small Area Population – We used mid-year population estimates from the ONS at 2001 LSOA level. This data provides population totals by age and gender for each of the 32,482 LSOAs in England for each year between 2001/2 and 2011/12. This data estimates the total resident population, including homeless people and people living in institutions such as prisons, barracks and nursing homes. All indicators requiring a general population

denominator focus on this resident population, based on ONS estimates, rather than the NHS registered population based on GP practice registers, as explained in Appendix A1: Indicator Definitions.

ADS: We used the NHS Attribution Data Set (ADS) of GP-registered populations. This data maps patients from the GP practices that they are registered with to the 2001 LSOAs they live in. We used ADS data for years 2004/5 to 2011/12. We used this data to map primary care supply and quality data provided at practice level to small area level, as described below and in Appendix A1: Indicator Definitions.

GMS - Our data on primary care supply were obtained from the annual National Health Service General and Personal Medical Services (GMS) workforce census, taken at 30 September each year. This data reports headcount and full time equivalent numbers of

general practitioners (GPs) at practice level for every GP practice in England. The data splits the GPs by type (allowing us to exclude trainees). However it does not include locum GPs or details of the supply of emergency primary care services outside of normal office hours. We used GMS data for years 2004/5 to 2011/12.

QOF – We took clinical process indicators in the UK “quality and outcomes framework” (QOF), the primary care pay-for-performance programme introduced in 2004 and collected at GP practice level. Although the QOF indicators only capture a limited part of clinical

practice, by international standards they are nevertheless one of world’s most comprehensive sets of primary care quality indicators. QOF data reports numbers of patients achieving the various outcomes as defined by the indicators as well as the numbers of patients excluded from performance calculations for various reasons and so classed as exceptions. In the base case analysis reported in Chapter Five: Results we use the “population achievement” figure which includes exception reported patients in the population denominator and hence treats them as representing poor quality. However, we also conducted sensitivity analysis using the “reported achievement” figure which excludes exception reported patients. We used QOF data for the year 2004/05 and 2011/12. Data on “exception reported” patients was not available in the first year 2004/5 and hence we see a blip in our “population achievement” QOF figures in 2004/5 where these exceptions are excluded from the calculation of the primary care quality denominator. Further details including the list of included QOF indicators are in Appendix 1: Indicator Definitions.

HES – We used inpatient hospital episode statistics (HES) data on admitted patient care to measure hospital waiting time, preventable emergency hospitalisation, repeat emergency hospitalisation, and death in hospital. This data set records finished consultant episodes (FCEs) i.e. the details of the patient’s period of care under the responsibility of a particular specialist. The HES data includes among other things details regarding the patient (age, sex, 2001 LSOA of residence) , as well as details about the specific hospital admission: admission date, type of hospital admission (emergency versus elective), length of hospital stay, reason for admission (diagnosis in terms of the tenth revision of the international classification of diseases ICD-10), any procedures undertaken during the admission, outcome of the admission and date of discharge from care of the specialist. We aggregated this HES data from FCE level to continuous inpatient spells that capture the entire hospital stay for the patient including hospital transfers – details of this aggregation are provided in section (ii) of

this methods chapter. HES data is collected in financial years i.e. from April to April. We used HES data from 2001/2 to 2011/12 in our indicators.

ONS Mortality – We used mortality data from the Office for National Statistics (ONS) estimates. This data tells us the date of death, cause of death (in terms of ICD-10 code), 2001 LSOA of residence, age and gender of the deceased for every person who dies in England. We used mortality data for the financial years 2001/2 through to 2011/12.