1.  In the NHS a strong emphasis is placed on equity. There are few official government reports or academic studies concerned with the underlying principles of the NHS that don't include some reference to equity or one of its close synonyms—fairness and social justice. This is the underlying idea of one of its founding principles: that it should be free at the point of use, available to all, irrespective of the ability to pay. Illogically, it is assumed that taxation and public service provision are somehow a proxy for equity, despite the fact that the commitment to equity is by no means unique to the NHS. Most OECD member countries have long achieved close to universal coverage of their population for a fairly comprehensive package of health services. In most of these countries, this is achieved as a result of a variety of public insurance arrangements aimed at ensuring equitable access.[391]

  2.  Whenever there is any serious consideration of alternative ways of structuring and organising healthcare in the UK, it comes up against the notion that the NHS delivers an equitable service: ours, it is assumed, is vastly superior to other countries. "To consider alternatives is to signal a willingness to depart from these ideals. In fact, to not consider alternatives is to show a lack of commitment to these ideals, while to defend the status quo is to endorse inequality."[392] As has repeatedly and conclusively been demonstrated, "there are social groups such as the poor or the ethnic communities who are significantly disadvantaged in their access to, and use of, the NHS, and that the present combination of bureaucratic allocation and professional authority actually favours the better off."[393]

HEALTH INEQUALITIES

  1.1  All the evidence suggests that there are entrenched inequalities in health in the UK. It is also clear that these inequalities are widening. However, to a substantial degree they are not the result of the healthcare system. This has been the finding of a number of reports. For example, it was the finding of the Black Report, delivered by Sir Douglas Black in 1980. His report showed unmistakably that death rates for many given diseases were higher for the lower social and occupational classes than for the higher classes, and that overall the health gap between rich and poor appeared to be growing.[394] "It was a shock to find that health inequality not only existed," as one commentator puts it, "but also seemed . . . to have increased in a situation where everyone could get health care without payment at a time of illness."[395] Black and his group did not, however, blame the NHS for this state of affairs. The real problems, in so far as they could be established, seemed to lie in issues such as "income, work (or lack of it), environment, education, housing, transport and "life-styles"".[396]

  1.2  In 1998 Sir Donald Acheson chaired a report for the Blair government entitled the Report of the Independent Inquiry on Inequality in Health. The Acheson report revealed that "unacceptable inequalities in health persist", that these "inequalities affect the whole of society",[397] and that "the gap in health between those at top and bottom of the social scale has widened".[398] The Acheson report, like the Black report before it, highlighted the link between social and economic disadvantage and health outcomes, and rather than blame the NHS its recommendations focussed on things like education, employment, benefits, housing, the environment, and "living standards".[399] Combating inequalities in health is about more than improving the healthcare service.

  1.3  In 2006, the DH found that health inequalities have been continuing to get worse. Not only, are lower socio-economic groups less healthy,[400] but the relative gap is growing. Between 1997-99 and 2002-04, "the trend shows a widening in the relative gap between infant mortality in the routine and manual group and in the total population".[401] This unedifying trend continues unabated. Sir Ara Darzi's interim report documents how the gap in life expectancy between the most deprived and least deprived areas in England is nearly 10 years for men.[402] E.g. premature death rates for coronary heart disease vary from 2.1 deaths per 10,000 of the population in the London borough of Kensington and Chelsea to 8.5 per 10,000 in Hartlepool.[403] The opportunity to access healthcare is actually worse in areas of greater need.[404]

UNEQUAL PROVISION

  2.1  What is becoming patently clear is that although inequality may be the result of multiple factors for which no health system can be directly blamed or credited, the NHS often does little to combat inequality—and may even make it worse. Inequality and inequity are not the same. Inequality is a factual matter, while inequity is a moral matter. When talking about the system, the NHS, it is inequity that is unacceptable. There are numerous ways that equity and inequity in healthcare can be defined, but the principle one concerns access. An equitable service offers equality of access to health care to individuals in equal need. This is generally referred to as horizontal equity, and it contrasts with vertical equity, when individuals with different levels of need consume appropriately different amounts of healthcare.[405] To put it another way, the treatment available to individuals should depend only on their need for treatment, not on factors that are irrelevant to that need. The most emotive factor irrelevant to need is, of course, socio-economic economic status.[406]

  2.2  Complex debates revolve around the definitions of these terms. For instance, the difference between access and utilisation means that if someone chooses not to use the service for whatever reason then it's not fair to then say that resultant inequalities in utilisation relative to need were inequitable. There are also awkward problems connected with defining need, such as whether it is in terms of health status or capacity to benefit,[407] and these have been outlined in some detail in numerous studies. In general, given how hard it is to attribute outcomes to choices, inequality in utilisation tends to be used as a proxy for inequalities in access, and different studies pitch for different qualifications of need based on a combination of detailed information about patients and carefully justified "value judgements".[408] Ultimately, a slew of studies has shown that "lower socio-economic groups use services less in relation to need than higher ones".[409] This was acknowledged by Tony Blair in 2003 when he said the NHS does not provide equitable access to services.[410]

HORIZONTAL INEQUITY

  3.1  One test of the horizontal equity of healthcare provision in the NHS is hip replacement, since it is a common, effective, low risk and long established health technology. In 2006 the York University Centre for Health Economics reported that studies of elective total hip replacement in the NHS between 1991 and 2001 have yielded striking examples of the unequal delivery of specialist health services across socio-economic groups. Survey data for people living in deprived areas suggests that they may be more likely to need hip replacements.[411] By setting this against administrative data which show that people living in deprived areas are less likely to receive hip replacement,[412] the York study was able to conclude that there is substantial socio-economic inequity in the use and delivery of elective total hip replacement.[413] There is evidence that this is a widespread phenomenon. Also in 2006, an article in the journal Rheumatology found that while need for hip and knee joint replacements was three times as high in the poorest quintile of the population as the wealthiest quintile, the number of operations were no more common.[414]

  3.2  Crucially—and this point cannot be emphasised enough—when the York team discussed their findings they observed that their study "did not include independent sector utilization". About "a quarter of hip replacements in England are undertaken in the independent sector." Relevantly, "[t]his non-NHS utilisation is concentrated among individuals and areas of high socio-economic status, particularly in the South East of England. Inequality in NHS utilisation therefore underestimates overall socio-economic inequality in utilisation".[415] Not only is there inequity in the provision of healthcare within the NHS, but also even more extreme inequity in the provision of healthcare across private and public services: that is, across healthcare taken as a whole. We shall return to this shortly.

GEOGRAPHICAL VARIATIONS

  4.1  The NHS is patchy and there are signs that it is better in richer areas of the country. Recent statistics on meeting the 18-week target show that there are wide variations in performance across the country, with just 33 per cent of elective patients receiving treatment within 18 weeks in Hastings & Rother PCT against 82 per cent in Blackpool PCT.[416] Where diagnostics—MRI and CT scans—are concerned, there are massive variations in waiting times. Whereas patients in Wales can expect to wait only 47 days for an MRI scan, those in the North East can expect to wait 100 days. And while there are a small number of hospitals, such as South Warwickshire General Hospitals NHS Trust, where you can get a routine MRI scan in less than ten days, there are equally a small number where you have to wait more than 170 days, such as the Royal United Hospital Bath NHS Trust.[417] Similarly, patients are waiting just three days at University College London to receive a CT scan—but 141 days at Norfolk and Norwich University Hospital NHS Trust.[418] Where you live therefore determines how long you have to wait to access NHS services.[419]

  4.2  Recent studies have also uncovered geographical variations in spending. Take expenditure on cancer treatment per cancer patient, where there is for example wide disparity between Nottingham City PCT, at £17,028 per cancer patient, and Oxfordshire PCT, at £5,182 per cancer patient.[420] Expenditure per heart disease death is more marked, ranging from £166,151 in Wakefield PCT to £17,241 in Calderdale PCT.[421] All of this means that there are variations in provision within specialties. Other surveys have found that a deaf person in one part of the country is likely to have more rapid access to a hearing aid than someone with the same condition in another part of the country.[422] The same applies to stroke victims, too, and wide variations are also reported in the diagnosis and treatment of urological cancer, and in the treatment of multiple sclerosis.[423] Dr Foster has found that in the emergency procedure, fractured neck of femur, if all trusts were up to the standard of the best performers then in the past three years more than 1,500 deaths could have been averted.[424] And "there is still a four-fold variation in mortality rates between organisations" for coronary artery bypass graft (CABG) procedures.[425] Variations in CABG treatment have consequences for equity. Julian Le Grand has shown that intervention rates of CABG or angiography are 30 per cent lower in the lowest socio-economic groups than in the highest.[426]

VULNERABLE GROUPS

  5.1  A good deal of attention has also rightly been focussed on the fashionableness of health conditions and the quality of treatment provided, what have been called the Cinderella services. This is particularly an issue in a tax-funded system where HM Treasury controls the overall expenditure, so there is a government decision about how much to allocate and to what services. Despite the fact that the UK population is ageing, and there's a higher proportion than ever before of older people in the community, the elderly depend on out-of-hospital care run by PCTs overloaded with responsibilities. It is, as the thinktank Reform notes, "the poor cousin of the acute sector".[427] The NHS is a long way from being able to offer an assurance of a high standard of care for admissions of frail elderly people, who then tend to stay for a long time. A recent study by the OECD has demonstrated that the elderly suffered substantial inequities, especially in hospitals or for specialist treatment and dental health. In terms of visiting GPs, the UK drops from 1st (for overall equity) to 9th (for equity for over 65-year-olds) in a list of EU countries.[428] If you are old and mentally ill things are even worse, as the Healthcare Commission found in 2006.[429]

  5.2  Services vary widely across the country in mental health care.[430] There are large disparities in spend by PCTs, from less than £75 per head per year to over £300 in 2004-05.[431] An enquiry by the King's Fund raised serious questions about variations in investment and gaps in information. The Audit Commission has found that this variation cannot be explained entirely by differences in levels of need, differences in volumes of activity, or differences in efficiency.[432] In addition, the Healthcare Commission has reported serious problems with variations in care, including a wide gap between the North and the South.[433] Further evidence of this has been gathered by Reform in a study of prescribing of atypical anti-psychotics in mental health. It showed that differing rates of prescribing in mental health are marked: fourteen of the bottom twenty performing PCTs were in the East Midlands and East Anglia, but only one in the South East; conversely, sixteen of the top performing PCTs were in the South East and London area and only four in the North or the Midlands.[434] Not only is mental health less well served than other conditions, but the quality of the service varies widely, with the relatively affluent south doing better than less prosperous parts of the country. As the Healthcare Commission said in 2006 when it published its first national review of adult community health services, "some disadvantaged groups are more likely than others to fail to receive services".[435]

ACCESS AND VOICE

  6.1  It is now widely acknowledged that the system militates against lower socio-economic groups. Since there is evidence to show that the provision of primary care services in deprived areas is getting worse,[436] despite concerted efforts to reverse the trend, there is much to suggest that "the inverse care law" operates, which is to say that areas which are poorer and therefore have greater health needs are less well served by the health service than wealthier and healthier areas.[437] The reality is more complex. Utilisation rates tell a different story. The majority of studies show that those of lower income and education status and ethnic minorities have higher use of primary care than those of higher income and education status. However, this is reversed in access to secondary care,[438] where "the rich are significantly more likely to see a specialist than the poor".[439] This indicates that under utilisation of secondary care by lower socio-economic groups doesn't appear to be caused by a reluctance to seek an initial consultation with a GP, despite barriers to treatment.[440]

  6.2  Generally this is taken to imply that, having made it to their GP, the poor "experience another set of difficulties, which manifest themselves in lower rates of referral to secondary and tertiary care, lower rates of intervention relative to need, and lower and irregular attendance at chronic disease management clinics."[441] Many barriers operate differentially—that is, are more significant for disadvantaged groups. Transport is one. Another is voice. Voice is simply a catchall for communication difficulties, language, literacy, assertiveness, articulation, self-confidence, ability to deal with professionals, and so on.[442] The idea is that the middle classes get more out of the health service because they are better at expressing their needs.[443] The idea of voice is suggestive. Information is not transmitted freely in the NHS—as would be expected in a properly functioning market—and standards vary wildly. Unofficial forces prevail, like learning, manners, and above all knowledge of how the system works, gained through establishing a complicit relationship with the best sources of information of all: the staff. Certainly, higher socio-economic groups are more likely to have family or friends who work in the health services, and even if these contacts are not directly used to gain access to services they act as an important source of advice on how to work the system.[444]

  6.3  Also relevant within the voice catchall is how pushy people are: at least one study—of hip replacement utilisation—has found "evidence of the effectiveness of the "sharp elbows" of the middle class in the welfare state".[445] The middle classes are just better at insisting on their rights and standing up to administrative gatekeepers than their less confident, less articulate fellow sufferers. They demand and get priority treatment. So ironically, an arrangement designed to remove the role of money in the system, far from abolishing inequality, reinforces it. The ability to get the most out of the NHS becomes a matter of survival of the fittest—or richest and most educated. The system offers different services to different people in different parts of the country, and quality and access vary widely. A completely new set of strategies or—as argued in Quite Like Heaven? —a reconfigured system will be required in order to improve patient pathways and join up care so that GPs effectively help patients navigate the care cycle. Better information and reporting of outcomes, made mandatory and made available to the public will also be axiomatic in a consumer-oriented model that harnesses market forces.

A TWO TIER SYSTEM

  7.1  As if this wasn't bad enough, because public and private healthcare systems exist in parallel, patients have differential access to services according to what they are willing or able to pay.[446] There has always been a two tier system in the UK, yet this runs counter to the ideal of social solidarity. Since the early 1990s, about 11.5 per cent of the UK population has had some form of private medical insurance, either personal or corporate cover.[447] There are some indications that, as of last year, the number has started to creep up. At any rate, the figures are particularly dramatic for those who know best about the quality of the NHS's service: the doctors themselves. The results of a 2007 survey of 1,700 GPs carried out by Hospital Doctor magazine found that 28 per cent of GPs have private medical insurance, and 33 per cent would prefer private treatment if they fell ill,[448] and a survey commissioned by BUPA found that for hospital consultants the figure rises to 55 per cent.[449]

  7.2  What's more, others are bypassing the blockages for specific treatments with out-of-pocket payments. Anecdotal evidence suggests that this is happening with increasing regularity. There has been no official attempt to map the scale of this trend, but there is a growing body of material which shows that patients are beginning to develop sophisticated approaches to purchase upgrades to their basic NHS care. As Allyson Pollock has written: "a "half way house" is beginning to emerge where NHS patients are invited to supplement their NHS care by paying a "top up" fee. Recent examples include maternity care, where patients can opt to buy a "superior" package of care, covering services which were once free to all women in labour, and MRI scans and dermatology, where patients bypass the waiting list by paying for them privately." [450]

  7.3  Nor should this surprise us. With PCTs struggling to balance their books, the range of treatments available on the NHS is being cut, creating hidden waits and postcode lotteries; but in our modern consumer age, people don't want to wait or suffer delays and they don't want to be told they can't have a life-saving or life-enhancing treatment by politicians who they don't trust at the best of times. It's also possible that all the rhetoric of choice in the NHS has stretched people's expectations even further, and as some private treatments become cheaper and more accessible in the marketplace, attitudes are becoming more amenable to using them. It is getting harder to credibly argue that healthcare in this country is comprehensive and available to all irrespective of the ability to pay. As a recent paper for Doctors for Reform has argued: "We run the risk of achieving the worst of all worlds: inequitable NHS provision combined with inequitable provision outside the service. In both worlds the least well-off are disadvantaged." [451]

  7.4  Recommendations for changes to improve the quality, performance and outcomes, along with consumer responsiveness, while also offering the prospect of reducing inequities, would have to be swingeing and systemic. Some tentative suggestions have been made in my recent book, Quite Like Heaven? It is beyond the scope of this paper to examine these possible options, but I would be more than happy to extrapolate orally or in a further written submission.

Nick Seddon

Author, Quite Like Heaven? Options for the NHS in a Consumer Age, Honorary Research Fellow, Civitas

February 2008

392   Seddon, N., Quite Like Heaven? Options for the NHS in a Consumer Age, London: Civitas, 2007. Back

393   Dixon, A., Le Grand, J., Henderson, J., Murray, R., and Poteliakhoff, E., Is the NHS equitable? A review of the evidence, London, LSE, 2003, p. 5. For a more strident treatment, see: Adonis, A., and Pollard, S., Class Act: The Myth of Britain's Classless Society, Harmondsworth: Penguin, 1998, p. 155. Back

394   Inequalities in Health: The Black Report and the Health Divide, Harmondsworth: Penguin, 1988, p. 2. Back

395   Bartley, M., Health Inequality: An Introduction to Theories, Concepts and Methods, Oxford: Polity Press, 2004, p. 8. Back

396   Inequalities in Health: The Black Report and the Health Divide, p. 4. Back

397   Acheson, D., Barker, D., Chambers, J., Graham, H., Marmot, M., and Whitehead, M., Report of the Independent Inquiry on Inequality in Health, London: HMSO, 1998, p. 1. Back

398   Acheson, D., et al., Report of the Independent Inquiry on Inequality in Health, 1998, p. 2. Back

399   Acheson, D., et al., Report of the Independent Inquiry on Inequality in Health, 1998, p. 36. Back

400   Hawe, E., Compendium of Health Statistics 2007, 18th edn, Oxford: Office of Health Economics, 2007, p. 91. Back

401   Tackling Health Inequalities: Status Report on the Programme for Action-2006 Update of Headline Indicators, London: DH, December 2006. Back

402   Darzi, A., Our NHS Our Future: NHS Next Stage Review Interim Report, London: The Stationary Office, 2007, pp. 19-20. Back

403   Gainsbury, S., "Heart death rates show a nation of inequalities", Heath Service Journal, 17/01/08. Back

404   DH, Press release: "Web tool launched to improve life expectancy in disadvantaged areas", 23/08/07. Back

405   Morris, S., Sutton, M., Gravelle, H., Inequity and inequality in the use of health care in England: an empirical investigation, CHE Technical Paper Series 27, York: University of York Centre for Health Economics, 2003, p. 28. Back

406   See: Dixon, A., et al., Is the NHS equitable? A review of the evidence, p. 6. Back

407   Stevens, A., Gillam, S., "Needs assessment: from theory to practice", BMJ, 1998; 316 (7142): 1448-52. Back

408   Cookson, R., Dusheiko, M., and Hardman, G., Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001, CHE Discussion Paper 15, York: University of York, May 2006, p. 1. Back

409   Dixon, A., et al., Is the NHS equitable? A review of the evidence, p. 2. See also: Morris, S., et al., Inequity and inequality in the use of health care in England: an empirical investigation, p. 28. Back

410   "The 1945 model, for all its great strengths, was not the answer to inequality", Tony Blair, speech to the Fabian Society conference, June 2003. Back

411   Cookson, R., et al., Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001, p. 2. Back

412   Cookson, R., et al., Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001, p. 1. Back

413   Cookson, R., et al., Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001, p. 1. Back

414   Steel, H., Melzer, D., Gardener, E., and McWilliams, B., "Need for and receipt of hip and knee replacements-a national population survey", Rheumatology, 2006; 45; 1437-1441. Back

415   Cookson, R., et al., Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001, p. 8. Back

416   DH, "18 weeks referral to treatment-commissioner based", 2008. Available at: http://www.performance.doh.gov.uk/rtt/downloads/monthly/RTT_Admitted_Commissioner_Oct07.xls Back

417   Dr Foster, How healthy is your hospital?, London: Dr Foster, 2007, p. 15. Back

418   Dr Foster, How healthy is your hospital?, p. 15. Back

419   Bosanquet, N., de Zoete, H., Haldenby, A., NHS refom: the empire strikes back, London: Reform, 2007, p. 33. See also: Dr Foster, How healthy is your hospital?, p. 14. Back

420   http://www.hsj.co.uk/images/Conservatives%20cancer%20spend%20table%20261107_tcm11-297712.doc Back

421   Gainsbury, S., "Heart disease rates show a nation of inequalities", HSJ, 17/01/08. Back

422   Bosanquet, N., et al., The Empire Strike Back, p. 39. Back

423   Dr Foster, How healthy is your hospital?, pp. 22-23. Back

424   Dr Foster, How healthy is your hospital?, p. 12. Back

425   Dr Foster, How healthy is your hospital?, p. 11. Back

426   Le Grand, J., "The Blair Legacy? Choice and Competition in Public Services", lecture to the LSE, February 2006. Back

427   Bosanquet, N., et al., The Empire Strike Back, p. 37. Back

428   Cited in DH, Better Care for Patients, London: DH, unpublished 2006, p. 16. Back

429   Healthcare Commission, Living well in later life: A review of progress against the NSF for older people, London: Healthcare Commission, 2006. Cited in Bosanquet, N., et al, The Empire Strike Back, pp. 37-38. Back

430   "Revealed the postcode lottery for mental health patients", Independent on Sunday, 29/10/06. Back

431   Audit Commission, Managing finances in mental health, London: Audit Commission, 2006, pp. 4, 19. Back

432   Audit Commission, Managing finances in mental health, pp. 4, 19. Back

433   Cited in Bosanquet, N., et al, Mental health services in the NHS: using reform incentives, London: Reform, 2006, p. 11. Back

434   Bosanquet, N., et al, Mental health services in the NHS, p. 13. Back

435   Healthcare Commission, Health watchdog highlights gaps in mental health care, London: Healthcare Commission, press release 29 September 2006, cited in Bosanquet, N., et al, Mental health services in the NHS, p. 12. Back

436   DH, Tackling Health Inequalities: Status Report on the Programme for Action-2006 Update of Headline Indicators, London: DH, December 2006. Back

437   Tudor Hart, J., "The inverse care law", The Lancet, 1971, 405-12. Back

438   See for instance: Morris, S., et al., Inequity and inequality in the use of health care in England: an empirical investigation, p. 3. Back

439   Van Doorslaer, et al., Income-Related Inequality in the Use of Medical Care in 21 OECD Countries, p. 6. Emphasis in original. Back

440   Morris, S., et al., Inequity and inequality in the use of health care in England: an empirical investigation, p. 29. Back

441   Dixon, A., et al., Is the NHS equitable? A review of the evidence, p. 29. My emphasis. Back

442   Hirschman, A., Exit, Voice and Loyalty, Cambridge, Mass.: Cambridge University Press, 1970. Back

443   Richards, H., Reid, M., Watt, G., "Socioeconomic variations in responses to chest pain: qualitative study", BMJ, 2002; 324 (7349): 1308. See also: Gardner, K., Chapple, A., "Barriers to referral in patients with angina: qualitative study", BMJ, 1999; 319 (9263): 1168-71. Back

444   Richards, H., Reid, M., Watt, G., "Socioeconomic variations in responses to chest pain: qualitative study", BMJ, 2002; 324 (7349): 1308. Back

445   Propper, C., Eachus, J., Chanc, P., Pearson, N., and Davey Smith, G., "Access to health care resources in the UK: the case of care for arthritis", Health Economics, 2005; 14; 391-406. Cited in Cookson, et al., Socio-economic inequality in small area use of elective total hip replacement in the English NHS in 1991 and 2001, p. 2. Back

446   Foubister, T., Thomson, S., Mossialos, E., McGuire, A., Private Medical Insurance in the United Kingdom, London: European Observatory on Health Systems and Policies, 2006, pp. 12-14. Back

447   Foubister, T., et al., Private Medical Insurance in the United Kingdom, p. xv. Back

448   Sergeant, H., "National Hypocrisy Service", Daily Mail, 09/02/07. Back

449   Templeton, S-K., "Senior doctors avoid being treated on NHS", The Sunday Times, 08/07/07. Back

450   Talbot-Smith, A., and Pollock, A. M., The New NHS, p. 180. Back

451   Charleson, P., Lees, C., and Sikora, K., Free at the point of delivery-reality or political mirage? Case studies of top-up payments in UK healthcare, London: Doctors for Reform, 2007, p. 5. Back