Guidance

AAA screening: identifying inequalities

Updated 24 June 2021

Applies to England

Identifying and addressing health inequalities is a legal duty for all screening services.

The NHS population screening inequalities strategy sets out how Public Health England (PHE) and its partners aim to tackle screening inequalities.

AAA screening providers, commissioners and other public health specialists should refer to the national strategy, this publication and other national screening inequalities guidance in order to support work to identify inequalities and interventions that can improve access and reduce inequalities.

Health inequalities can exist across a range of characteristics or dimensions, including social deprivation, geography and the 9 protected characteristics described in the 2010 Equality Act. And screening inequalities can occur at any point along the screening pathway.

Some groups are less likely to attend AAA screening and this can increase health inequalities. Social deprivation is associated with both poorer attendance at screening and follow-up, and is associated with a higher chance of having an AAA.

1. Health equity audit guidance

AAA screening providers should use the PHE screening health equity audit (HEA) guidance in conjunction with the generic PHE Health Equity Audit Tool (HEAT) to:

• identify health inequalities for the eligible cohort
• assess health inequalities in relation to the screening service
• identify actions to take to help reduce those inequalities

2. Data reports

The first step towards identifying interventions to improve access to services and outcomes is to identify if there are any inequalities. To do this you need data and to be able to interpret it.

AAA screening providers have access to a data report within the national AAA Screening Management and Referral Tracking (SMaRT) IT system. The report includes measures such as completeness of offer, coverage and uptake of initial screening by deprivation group and different geographies. There is also information on attendance by ethnic group and surveillance of men within secure units.

A screening standard for coverage in the most deprived 3 Index of Deprivation deciles was introduced from April 2020. This standard allows providers to easily see how coverage in the most deprived 3 deciles compares with coverage overall for their area.

3. Evaluation

When planning changes to how your service operates it is important to decide what outcome you hope to achieve and how you will know if you have achieved it. You will need to consider if the change:

• has any positive or negative impacts that you weren’t expecting
• is cost-effective
• is sustainable

You will also need to consider what factors influenced the achievement or non-achievement of the outcome.

There are many different ways to evaluate changes depending on the type of change. You can use routine data to measure a change that affects a large number of men. However, the most disadvantaged groups often relate to a small number of people and it may not be possible to use data to see if there is an increase in access to the screening service. In these circumstances, you can evaluate whether a new process is working efficiently and effectively or you can evaluate service user satisfaction.

3.1 Example 1 – large numbers

A provider has decided to provide screening on a mobile unit that travels to deprived communities. The provider can compare uptake in the area using the deprivation and ethnic group report before and after using the mobile unit to see if there is an increase. The provider may also notice an increase in the number of men self-referring for screening. The provider would need to consider if the mobile unit is cost-effective and sustainable.

3.2 Example 2 – large numbers

A provider wants to implement invitation letters with a GP endorsement. They could send out endorsed letters to half the eligible men and standard letters to the other half. They can then compare uptake to see if there is an increased chance of attending for men receiving the endorsed letter. The provider would also need to check for any unforeseen negative impacts.

3.3 Example 3 – small to medium numbers

A provider has difficulty screening men who live in a number of care homes and cannot always attend screening at the GP practice. The provider introduces a new procedure to screen in the care homes. The provider could:

• gather qualitative feedback from the care homes about the organisation of screening and quality of communication
• monitor if clinics had to be cancelled at short notice or if there were any screening safety incidents
• gather feedback from the screening technicians about their experience of the screening location

3.4 Example 4 – small numbers

A provider is made aware of a man with learning disabilities who wants to attend screening. The provider develops a new protocol working with learning disability nurses and the individual’s carer. The provider evaluates the intervention by looking at whether the new protocol improves the efficiency of the screening process for subsequent men with learning disabilities. This may include identifying men with learning disabilities.

The provider may also want to look at feedback from men, carers and learning disability nurses to understand their experience of the service. If personal connections are critical to ensuring the protocol runs smoothly then the provider may consider if the protocol can be sustained long term when there are staff changes.