Equality and health inequalities assessment (EHIA): GID-IND10338 Asthma: annual review (high risk patients)

What approaches have been used to identify potential equality and health inequalities issues during indicator development?

Checking equality impact assessment (EIA)/equality and health inequality impact assessment (EHIA) documents of the BTS/NICE/SIGN asthma guideline NG245, and other NICE asthma indicators.

Desktop searches during development of the indicator.

What potential equality and health inequalities issues have been identified during indicator development?

Socio-economic factors need to be considered (in particular those in the lower socio-economic groups). Reports from Asthma UK 2018 and Asthma + Lung UK 2023 found that people in lower socio-economic groups have higher rates of uncontrolled asthma and poorer outcomes, for example they are more likely to go to hospital for their asthma. This may be because they are exposed to more causes and triggers of asthma, such as smoking and air pollution.

In the UK, people of South Asian origin with asthma experience excess morbidity, with hospitalisation rates three times those of the majority White population and evidence suggests that South Asian children with asthma are more likely to suffer uncontrolled symptoms and hospital admissions with acute asthma compared to White British children. In this population, there is also a need for consistent, effectively communicated information, especially regarding medication.

People with cognitive impairment, learning disabilities, language and communication difficulties, and mental health difficulties, may experience poorer outcomes due to, for example low adherence to treatment. This population may need additional help with their self-management to improve factors such as inhaler technique and adherence.

Adherence to medication is more difficult for the homeless.

There is geographical variation in the availability of fractional exhaled nitric oxide (FeNO) testing.

How have the committee's considerations of equality and health inequalities issues identified in 1.2 been reflected in the indicator?

Populations noted in section 1.2 which have been identified as being at risk of poor outcomes will be specifically targeted by this indicator, which is designed to focus on annual reviews in high-risk groups.

QOF data for 2023-24 indicated that 65% of all people with asthma on the register had a review in the preceding 12 months (indicator AST007). Annual reviews can help support people with asthma to self-manage their condition. Focussing on annual reviews in high-risk groups may help to reduce inequalities by improving asthma control and lowering risk of poor outcomes.

The need to provide culturally appropriate care and care for people who may need additional support is included within the indicator as it highlights the need for a personalised action plan.

FeNO has not been included as a means of assessing asthma control within an asthma review. If progressed, the indicator will be reviewed as access to FeNO increases.

Could any indicators potentially increase inequalities?

Indicators focusing on people most at risk of poor outcomes have the potential to decrease focus on those with less severe asthma. The existing indicator for annual reviews in the whole asthma population (IND273) will continue to be used alongside the new indicator for high risk patients.

Based on the equality and health inequalities issues identified in 1.2 do you have representation from relevant stakeholder groups for the indicator consultation process, including groups who are known to be affected by these issues? If not, what plans are in place to ensure relevant stakeholders are represented and included?

Relevant stakeholders for the consultation include: Association of Respiratory Nurse Specialists, Asthma and Lung UK, Primary Care Respiratory Society UK, Rethink Mental Illness, Royal College of General Practitioners

Has it been proposed to exclude any population groups from coverage by the indicator? If yes, could these exclusions further impact on people affected by any equality and health inequalities issues identified?

The indicator does not include people with asthma who are not at risk of poor outcomes. These people are, however, included in the universal indicator for asthma reviews (IND273). Given that the focus of this additional indicator is on reducing health inequalities, this exclusion is justified.

Children aged 5 years and under have been excluded from this indicator due to difficulties in diagnosing asthma in under 5s. This is also in line with existing quality and outcomes framework (QOF) indicators:

What questions will you ask at the stakeholder consultation about the impact of the indicator on equality and health inequalities?

Do you think there are any barriers to implementing the care described by these indicators? 

Do you think there are potential unintended consequences to implementing/ using any of these indicators? 

Do you think there is potential for differential impact (in respect of age, disability, gender and gender reassignment, pregnancy and maternity, race, religion or belief, and sexual orientation)? If so, please state whether this is adverse or positive and for which group. 

If you think any of these indicators may have an adverse impact in different groups in the community, can you suggest how the indicator might be delivered differently to different groups to reduce health inequalities?

A question will also be asked about the way that high risk groups are defined in the indicator.