Health inequalities tool 3 - Prepare your own quality improvement project

Quality improvement (QI) can be used to improve NHS services that aim to reduce child health inequalities. When starting a QI project, consider the following factors.
Icon of report with pie chart and checkmarks, with pen - with background of repeated icon of family

Always collaborate with your local communities and families 

Working with families, voluntary organisations and community leaders is vital to understanding local challenges and solutions for health inequalities. For example, during a project addressing high rates of hospital attendances for bronchiolitis, parent champions highlighted that for many families a first aid box is prohibitively expensive. They had local knowledge for accessing free over-the-counter medication and included the programs available in their peer support to empower families to manage their unwell children at home rather than having to rely on emergency services.

This demonstrates a local community’s ability to identify and address challenges when supported by local health care services.  

What do children and young people think?  

Please involve children and young people in coming up with ideas! We’ve got lots of ideas and want to work with you and others to make a difference and make things better for everyone. It works best for us if we can come together as a group and work on a project and to have space and time for parents and children/young people separately.

There is training on how to do this and resources created by children and young people from RCPCH &Us.

We are worried about how doctors and nurses know that we are struggling with things like poverty when our appointments might be on the phone or on video with our cameras off. We know that there are quality improvement projects that people do- maybe this could be one of them! Think about different ways that you can check in with us if you don't get to see us, or different tools you can use like HEADSS or the Poverty Proofing resources from Children North East.

Explore limitations of choice 

Strategies placing the onus on families (such as solely focussing on education about health choices) are unlikely to lead to sustained reduction in inequality as this will not affect the underlying problems. It’s worth considering whether, for example, there are barriers to families being able to cook healthy food at home. These may be a) ‘clock’- time constraints b) capacity- any limitations of physical or mental health, or practical/ cognitive skills or c) ‘cost’- are there financial disincentives to eat in a healthy way?  

Seek out the inverse care law, and demonstrate it with data

As noted in our first tool, the inverse care law, put simply, is when children and young people living in poverty have less access to healthcare, and a worse experience of care when they get there.

It’s important to consider how health services impact on inequalities: it costs families approximately £35 to attend a respiratory clinic appointment and 8% of families reported missing appointments because of financial difficulties11 . How we offer appointments and adjust outpatient services to families’ needs is crucial in addressing heath inequalities. 

An audit is an important tool to assess how services may contribute to health inequalities (for example, by assessing outcomes by the Index of Multiple Deprivation decile). A recent report found that amongst children with chronic renal failure, those from deprived backgrounds were significantly less likely to receive a pre-emptive kidney transplant, and this was not explained by their clinical status or time of presentation to specialist services12 . Knowing the inequalities in the services we provide is the first step for finding solutions.

What do children and young people think?

Think about the cost of healthcare and how it is different for different groups. If you are a young adult with epilepsy, you might not be able to drive, but also might not be able to afford the bus or train tickets to go to specialist appointments, especially if you have gone away to university, This needs to be thought about and talked about as part of our transition as it might be easier for us to talk about our worries with our paediatric teams and to get you to help us talk to our adult teams.

Look for synergies driving poor outcomes

Taking childhood asthma as an example, children living in poverty are more likely to live in poor quality housing with problems with damp and mould, increasing their risk of coughing and wheeze. Their families are more likely to experience fuel poverty and live in high areas of crime, making adequate ventilation harder, and once they are outside are more likely to live in areas of high outdoor pollution. Whilst air pollution during pregnancy is a known risk for asthma, the risk is greatest in women experiencing psychological stress, which in turn increases the likelihood of antenatal smoking – another risk factor for asthma.

During your respiratory clinic, it is therefore important to address all these “core determinants” of asthma. Knowing what services are available to support a parent with household debts, benefits and housing disrepair becomes just as important as knowledge of the British Thoracic Society asthma ladder.  

Be clear about what your goal is

Are you mitigating the effects of inequalities or addressing the inequality itself? Both are valid but it’s important to distinguish between the two. Generally, action at an individual level will be targeted at mitigating the impact of poverty, rather than poverty itself.

However, poverty is not just about income; even changing the way you run clinics to make it cheaper for people to attend has an impact on their financial situation.  

Explore options within your organisation

Child poverty and its impact on child health are nothing new and have been steadily increasing for the last decade at least. It is unlikely that you are the first person in your organisation to consider supporting children, young people and families; you are likely to find that multiple small standalone efforts by individuals or teams within your organisation already exist.

Uniting the existing efforts of your colleagues might enable you to achieve greater things as a team, whilst removing the reliance on a single person's drive and passion that can be both the heartbeat and eventual demise of smaller projects.

More from the health inequalities toolkit

  • 11Chadwick B, Hayden P, Sinha I. The cost of the clinic visit - a short research project exploring the cost of clinic appointments, financial and otherwise, to families visiting Alder Hey Children’s Hospital. European Respiratory Journal 2020; 56. DOI:10.1183/13993003.congress-2020.589
  • 12Plumb LA, Sinha MD, Casula A, et al. Associations between Deprivation, Geographic Location, and Access to Pediatric Kidney Care in the United Kingdom. CJASN 2021; 16: 194–203