Guidance

Health Equity Assessment Tool (HEAT): executive summary

Updated 25 May 2021

1. What are health inequalities?

There is considerable local and international evidence of significant inequalities in health. Health inequalities are systematic, avoidable and unjust differences in health and wellbeing between different groups of people. There is clear evidence that reducing health inequalities improves life expectancy and reduces disability across the social gradient. Tackling health inequalities is therefore a core part of improving access to services, quality of services, and health outcomes for the whole population.

Public Health England (PHE) fulfils the Secretary of State for Health and Social Care’s statutory duty to address health inequalities. Reducing health inequalities is also an important priority within PHE’s strategy 2020 to 2025, PHE’s Infectious Diseases Strategy 2020 to 2025 and within the NHS Long Term Plan.

Health inequalities in England exist across a range of dimensions or characteristics, including the 9 protected characteristics in the Equality Act^{[footnote 1]}: socioeconomic position, occupation, geographic deprivation and membership of a vulnerable group. As shown in Figure 1, these dimensions overlap.

Figure 1: overlapping dimensions of health inequalities

Health inequalities may be driven by:

• different experiences of the wider determinants of health, such as the environment, income or housing
• differences in health behaviours or other risk factors, such as smoking, diet and physical activity levels
• psychosocial factors, such as social networks and self-esteem
• unequal access to or experience of health services^{[footnote 2]}

These conditions influence our opportunities for good health and how we think, feel and act, and this shapes our mental health, physical health and wellbeing.

Coronavirus (COVID-19) has not only replicated existing health inequalities, but in some cases, has increased them, through its disproportionate impact on certain population groups^{[footnote 3]}. Analyses have shown that older age, ethnicity, male sex and geographical area are associated with the risk of getting the infection, experiencing more severe symptoms and higher rates of death^{[footnote 4]}.

Action on health inequalities requires improving the lives of those with the worst health outcomes, fastest. The Health Equity Assessment Tool (HEAT) aims to empower professionals across the health and the wider system landscape to do this. It supports the user to identify practical action in their work programme or service to address health inequalities and consequently improve health outcomes. HEAT is highly pertinent in the context of COVID-19, enabling colleagues in the system to consider which groups have been particularly affected by the pandemic, and mitigate any negative impacts in collaboration with other system partners.

2. Development of HEAT

In 2019 to 2020, the PHE National Health Inequalities team launched a review and refresh of the existing HEAT. This was driven by requests from across the system for a practical framework that could be used with a range of stakeholders to identify and support local action. A need was identified for a resource to enable professionals to systematically address inequalities and equity in programmes and services to drive change and generate improvements.

The comprehensive review and engagement process aimed to ensure that the tool is succinct, user-friendly and practical. It focused on simplifying the structure and reducing the complexity of the tool, improving the language use and including specific prompts to address issues relating to communities and mental health.

A brief evidence review was undertaken, using systematic and transparent methods, which highlighted the main benefits of using HEAT and shaped the development of the tool.

A comprehensive and inclusive engagement process was devised to ensure the next iteration of the tool was co-designed with stakeholders and was user-driven. This involved engagement with a range of system players that included PHE Centre Health and Wellbeing Leads as part of a dedicated Task-Finish group, as well as with National Screening and Immunisation Teams, and other teams across and beyond PHE.

Recognising that there are other tools in the system, a rapid comparison of other health equity assessment tools was completed, which can be accessed in the HEAT e-learning. This identified that, in comparison with other tools and resources, this HEAT is unique in offering a simple yet thorough framework and set of principles for assessing and driving action on health inequalities among multiple stakeholders across the system.

The refreshed tool provides an easy-to-follow template that can be applied flexibly to suit different work programmes and services and can be easily imbedded where appropriate into existing systems and processes, including business planning, annual service reviews or commissioning cycles.

PHE has also recently developed the Health Equity Audit Guide for Screening Providers and Commissioners. This guidance is designed to be used in conjunction with the full or simplified HEAT tool, but has been tailored to be more specific to issues of relevance to screening services.

The HEAT and screening-specific guidance together aim to support those involved in the commissioning and local delivery of national screening programmes to fulfil their legal inequalities duties and ensure equitable access throughout the screening pathway. The tools can be used in a variety of contexts. This could include completing a health equity audit for an individual screening service or to assess and address specific inequalities issues associated with a change in service delivery, for example, in response to the COVID-19 pandemic.

3. About HEAT

HEAT is the main tool for professionals across the public health and healthcare landscape to:

• systematically address health inequalities and equity-related to a programme of work or service
• identify what action can be taken to reduce health inequalities and promote equality and inclusion

The programme of work for HEAT consists of the following:

• HEAT – full version
• HEAT – simplified version
• an e-learning module, co-produced with Health Education England, that will equip professionals with essential skills in undertaking a HEAT assessment
• practice examples, demonstrating practical application of the tool and the main benefits of applying it in different work areas
• a brief glossary of terms is provided at the end of this document

There are several major benefits to using HEAT, including that it:

• provides a clear and straightforward format for professionals across the health and wider system landscape to assess health inequalities in relation to their work or service
• supports professionals to determine concrete actions to tackle these inequalities
• can be adapted for use across a range of different work programmes and services, and can be easily imbedded into existing systems and processes, for example, as part of business planning, the commissioning cycle, service review or COVID-19 recovery planning
• encourages the user to review their work 6 to 12 months after the initial assessment, enabling consideration of lessons identified and areas for continued focus (for example, service improvements)

4. How to use this resource

4.1 Audience

The tool is intended for use by healthcare professionals and the public health system including:

• local authorities (LA)
• screening and immunisation teams (SILS) and service providers
• the voluntary, community and social enterprise (VCSE) sector
• other sectors with a significant impact on health, wellbeing and equity, such as housing, welfare and education

It is also suggested for NHS staff at national and local level, including in:

• Clinical Commissioning Groups (CCGs)
• Sustainability and Transformation Partnerships (STPs)
• Integrated Care Systems (ICSs)
• Primary Care Networks (PCN)

HEAT is best used by a group that includes professionals who can speak to the equity issues for their own communities or in a dialogue with wider stakeholders and service providers.

4.2 Structure

The tool is structured in 4 main stages:

1. Prepare.
2. Assess.
3. Refine and apply.
4. Review.

HEAT is designed to enable the user to consider health inequalities and equity at the start of a work programme, but it can also be used retrospectively. It is a flexible tool that can be used in its entirety or, alternatively, selected questions or groups of questions can be asked for specific purposes.

In practice, an assessment is likely to be iterative and can be carried out multiple times throughout a work programme or during service delivery, to continuously improve the contribution of the work to reducing health inequalities.

4.3 Full and simplified versions

HEAT can be used either for a rapid assessment or in a more in-depth way, depending on the requirements of the users. Therefore, we developed 2 versions of HEAT: a full and a simplified version.

It is recommended that users complete the full version of HEAT, as this will allow a more comprehensive assessment of health inequalities.

However, the simplified version may be more appropriate if working with stakeholders from various backgrounds who are less familiar with public health concepts and issues.

4.4 Information and research

When completing HEAT, you will need to use evidence to support your responses. This includes data and expertise on health inequalities and successfulness of interventions. In some cases, this data may be limited and you may need to commission new research or engage with partners to obtain information, including local authorities, PHE and NHS England.

If gathering additional data is not possible, you may need to notify decision-makers about the need for such data. Without good data, HEAT should be used cautiously, ensuring that the effects of your work on particularly vulnerable groups are not overlooked.

5. Additional resources

When completing HEAT, the following resources may be useful:

Health Equity Audit Guide for Screening Providers and Commissioners – to support users to plan and conduct their HEAs.

NHS England Equality and Health Inequality legal duties and NHS England resources

Essential data on health inequalities

PHE Health Inequality resources

The Equality Act 2010: What do I need to know? A summary guide of the Equality Act 2010 for public sector organisations

The Data and Knowledge Gateway

The Public Health Outcomes Framework

Community-centred approaches guide to evidence

It may be useful to tie your completion of HEAT into a sector-led improvement programme in your area, for example, Developing Excellence in Local Public Health (DELPH).

6. Glossary

Health inequalities: differences in health status or in the distribution of health determinants between different population groups.

Health inequity: differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age^{[footnote 5]}.

Shifting work upstream: focusing on the root causes of health inequalities – the ‘causes of the causes’.

Wider determinants of health: a diverse range of social, economic and environmental factors that impact on people’s health. Such factors are influenced by the local, national and international distribution of power and resources which shape the conditions of daily life.

7. Acknowledgements

Lina Toleikyte led the review and refresh of the HEAT programme. We would like to thank all those in the PHE National Health Inequalities Team, the Healthy Communities Team, PHE Libraries, PHE Centre Health and Wellbeing Leads as part of a dedicated Task-Finish group, National Screening and Immunisation Teams and the PHE antimicrobial resistance (AMR) lead for their valuable contributions.

8. References

1. The Equality Act 2010, section 4. ↩

2. Public Health England. Place-based approaches for reducing health inequalities 2019. ↩

3. Public Health England. Disparities in the risk and outcomes of COVID-19 2020, page 4. ↩

4. Public Health England. Beyond the data: Understanding the impact of COVID-19 on BAME groups 2020, page 4. ↩

5. World Health Organization. 10 facts on health inequities and their causes 2017. ↩