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Link to S.H padlet page

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Relevant in health & social care

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Key legislation - Health and safety legislation

Safe practice is very important to the promotion of dignity in care. There are a number of legislative measures and regulations to support health and safety at work. These are intended to protect people in work, those using services and the wider public. The Health and Safety Executive (HSE), local authority Trading Standards and the Care Quality Commission (CQC) can all bring prosecutions against care providers who breach health and safety standards.

Case examples:

A care home in South Lanarkshire was fined for breach of Section 3 of the Health and Safety at Work etc. Act 1974, following the death of Mrs Elizabeth Stevenson, 88. Mrs Stevenson broke her neck in a fall. 'BUPA Care Homes (Carrick) Ltd admitted to failing to review and update a risk assessment for Mrs Stevenson and failing to provide adequate instruction and supervision to their employees engaged in moving and handling residents' (Health and Safety Executive 2012).

Essex County Council was prosecuted after a child with severe learning and physical disabilities almost drowned in his school's swimming pool. The council had failed to provide schools with adequate information and guidance on how to safely manage and run their swimming pools (Health and Safety Executive 2012a).

Health and safety legislation and regulations

Health and Safety at Work Act 1974

The Act covers a wide range of issues relating to workplace health, safety and welfare across different sectors. Statutory instruments have developed to support the implementation of the Act and provide an interface with European regulations. The HSE holds enforcement powers which can result in unlimited fines and prison sentences. Employees have a general obligation under the Act to take care of others and cooperate with employers' health and safety requirements.

Manual Handling Operations Regulations 1992 (amended 2002)

Manual handling is a major issue for care providers as people with limited mobility need to be assisted safely to move and transfer. It is important this is done in a way that respects the dignity of the individual. While employers are required to ensure that they comply with the regulatory framework, this does not mean that an individual's human rights can be disregarded. What is required is a balanced approach that reduces risks for workers while at the same time maintaining the dignity, privacy and autonomy of those they are caring for. The problem of lifting an overweight person, for example, must be solved not ignored. For example, a county council, concerned for the health of its employees, imposed a blanket ban on manual lifting of people using services. Unfortunately this resulted in certain people not receiving the community care to which they were entitled. The court held that the guidelines on manual lifting did not prohibit manual handling of people, nor operate a cut-off above which they would be too heavy to lift manually. Failure to lift these people could leave them stuck in a bath or on a lavatory, or suffering from bedsores. This created a potential breach of Article 3 of the HRA (the right not to be subject to inhuman or degrading treatment). Care workers' rights to a safe working environment must be respected, but these require safe working practices to be devised, not blanket bans that restrict levels of service [R v East Sussex County Council (2003)].

Control of Substances Hazardous to Health 2002

In the care sector these regulations may apply to cleaning materials and medications that may be dangerous if not used properly. Care providers must protect staff and service users from harm by ensuring that potentially dangerous substances are safely stored and that staff that use them are properly trained to do so.

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995

Employers, the self-employed and 'responsible persons' (people in control of work premises) have an obligation to report death or serious workplace accidents, occupational diseases and specified dangerous occurrences (near misses) to the HSE.

Health and Safety (First Aid) Regulations 1981

Employers must ensure that first aid equipment and trained first-aiders are present in the workplace and that employees are aware of first aid arrangements.

Food Safety Act 1990, Food Safety (General Food Hygiene) Regulations 1995 and Food Safety (Temperature Control) Regulations 1995

The Food Safety Act covers the preparation, storage and service of food and requires the registration of food businesses whether they are run for profit or not. A 'food business' includes canteens, clubs and care homes. The CQC requires that care services ensure that the food and drink they provide is handled, stored, prepared and delivered in a way that meets the requirements of the Act. The local authority is responsible for enforcement through environmental health and Trading Standards. The Food Standards Agency (FSA) can intervene where local authorities fail to meet the requirements and in emergency situations.

Quality in care

Circumstances that influence dignity, such as living conditions in care homes, are governed by a whole host of regulations. The CQC is the health and social care regulator. It has published guidance for compliance with the Essential Standards of Quality and Safety. However, personal assistants paid for through direct payments and personalised budgets and day services are unregulated.

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Dignity in care - Key legislation: Health and safety legislation

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Safe practice is very important to the promotion of dignity in care. There are a number of legislative measures and regulations to support health and safety at work. These are intended to protect people in work, those using services and the wider public.

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Health and Safety at Work Act 1974. The Act covers a wide range of issues relating to workplace health, safety and welfare across different sectors. ... Employees have a general obligation under the Act to take care of others and cooperate with employers' health and safety requirements.

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Health and Safety at Work Act 1974. The Act covers a wide range of issues relating to workplace health, safety and welfare across different sectors. ... Employees have a general obligation under the Act to take care of others and cooperate with employers' health and safety requirements.

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Health & Social Care

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Data Protection Act Management of Health and Safety

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Legislation and Guidelines P2 Outline how legislation, policies and procedures promote health, safety and security in health and social care settings. M1 Describe how legislation, policies and procedures promote health, safety and security in health and social care settings.

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Verbal descriptio

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Unit 11 - Services in Health and Social Care - Key Terms Flashcards | Quizlet

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Unit 11 key words and phrases. Learn with flashcards, games, and more - for free.

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- Health and safety legislation. Safe practice is very important to the promotion of dignity in care. There are a number of legislative measures and regulations to support health and safety at work. These are intended to protect people in work, those using services and the wider public.

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Care Quality Commission
What is legislation in health and social care?

Regulations for service providers and managers: relevant legislation

Related legislation Applies to (reg no)
The Health and Safety (Miscellaneous Amendments) 2002 | HSCA 12, 15, 18
Health and Social Work Professions Order 2001 | HSCA 18
Human Rights Act 1998 | HSCA 5, 9, 10, 13, 15, 18
The Human Tissue Act 2004 | HSCA 10

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The following table contains hyperlinks to legislation that may be relevant to health and social care. We have identified the key Acts and regulations that are likely to be applicable. However, this list is not intended to be exhaustive and there may be further relevant legislation that is not identified.

The Care Quality Commission cannot accept responsibility for the accuracy of the information that appears in these hyperlinks as the information is provided by other organisations. You should therefore take steps to satisfy yourself that legislation you rely on is up to date and has not been subject to further amendment. Please help us to keep this list up to date by reporting any broken links you find using the link on the right of this page.

Help us improve this page

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Regulations for service providers and managers: relevant legislation

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The following table contains hyperlinks to legislation that may be relevant to health and social care. We have identified the key Acts and regulations that are likely to be applicable. However, this list is not intended to be exhaustive and there may be further relevant legislation that is not identified.

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Prevention

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Secondary and Tertiary Prevention Examples of Primary Care Prevention Promoting

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Secondary Care Prevention Defined Tertiary Care Prevention

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Primary, Secondary and Tertiary Prevention Examples of Primary Care Prevention Promoting exercise Gym stipend or point system Smoking prevention and education Stress management Anger management Sleeping health Dietary/Nutrition practices Dental education (tied in from Wolff) Immunization Examples of Secondary Care Prevention Hypertension vs Coronary disease Curbing disease prevention Sympathetic understanding of all causes Smoking cessation Treatment through screening programs Screenings!

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Family's spy camera show Birmingham care home abuse

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Family's spy camera show Birmingham care home abuse

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A care worker was caught slamming the head of a 77-year-old woman with dementia into a chair on secret CCTV installed by her family.

Betty Boylan's relatives put a camera in her room at Bupa's Perry Locks home in Birmingham after they found bruises on her, a court heard.

Bina Begum, 49, was given a 12-month community order after admitting ill treating and neglecting Mrs Boylan.

Bupa said she had been dismissed and her actions were "unacceptable".
Read more news for Birmingham and the Black Country
Noreen Ashraf, prosecuting, told Birmingham Magistrates' Court Mrs Boylan was "left slumped in her chair with significant leaning to her side" on 15 September.

She said: "The complainant does want to move her arm. The defendant forces her arm and pushes her back into the chair.

"The complainant cries out. She slams her head back into the chair with significant force to cause the chair to rock."

Mrs Boylan's daughter, Bernadette Jarvis, said: "To a vulnerable person as well who can't say anything, there's just no words to explain what she's done to be quite honest."

The family also captured images of deodorant being sprayed in the woman's face, which is under investigation.

West Midlands Police said a 43-year-old woman had been voluntarily interviewed "in connection with an assault on a 77-year-old woman in a care home" and inquiries were ongoing.

Bupa Care Services director of quality Vivienne Birch said the apparent actions "of these individuals are unacceptable".

She said they were "immediately removed" from the home and they had since been formally dismissed.

"We were shocked and saddened by the footage. We're deeply sorry this happened and the distress it has caused Mrs Boylan's family.

"We're proud of the care our staff provide and do not tolerate behaviour like this at any of our homes."

The family had other images of a male patient in Mrs Boylan's room.

In response, the Bupa Care Services director of quality said: "Our night staff found the resident sitting in the wrong bedroom while doing their regular checks and he was safely taken back to his room.

"He had only been at the home for a few days and was confused by his surroundings."

Begum, of Teddington Grove, Perry Barr, who admitted wilful ill treatment and neglect, said she accepted her actions were "reckless rather than intentional or deliberate" in a letter read out in court.

She was also ordered to carry out 40 hours of unpaid work and fined £270.

Nazia Jan, defending, said Begum was "very, very remorseful".

She said: "It's cost her her chosen career... This act was completely out of character, blemished her good character and caused her unquantifiable distress."

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Family's spy camera captures carer abuse

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A care worker was caught slamming the head of a 77-year-old woman with dementia into a chair on secret CCTV installed by her family. Betty Boylan's relatives put a camera in her room at Bupa's Perry Locks home in Birmingham after they found bruises on her, a court heard.

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Six out of 11 care workers who admitted a total of 38 charges of neglect or abuse of patients at a private hospital have been jailed.

Five other workers from Winterbourne View near Bristol were given suspended sentences after the acts of abuse were uncovered by BBC Panorama.

Ringleader Wayne Rogers, 32, who admitted nine counts of ill-treating patients, was jailed for two years.

Judge Neil Ford QC said there was a "culture of cruelty" at the care home.

'Vile and inexcusable'

Judge Ford said no attempt was made to provide a caring environment and if the abuse had not been uncovered by the BBC, it would have continued.

He told the sentencing hearing the home had been "run with a scandalous lack of regard to patients and staff".

"What happened was a gross breach of trust," he said.

Alison Dove, 25, of Kingswood, was jailed for 20 months as was Graham Doyle, 26, of Patchway. Both pleaded guilty to seven charges of abuse.

Addressing Dove, Judge Ford said: "You suggested it was born of boredom during long shifts and that you had viewed patients as playthings."

He also referred to a letter Doyle wrote to him, in which the defendant had described his own behaviour as "disgusting, vile and inexcusable".

'Bite face off'

Judge Ford then told Doyle: "You are considered genuinely remorseful and haunted by guilt.

"But your treatment of Simone Blake was often cruel, callous and degrading. It was always wholly unjustified."

Prosecutor Kerry Barker QC, said care watchdogs failed to act on repeated warnings of "inhumane, cruel and hate-fuelled treatment" of patients.

"The so-called restraint techniques were used to inflict pain, humiliate patients and bully them into compliance with the demands of their carers," he said.

Abuse of five residents at the home featured in footage played to the court during a week of sentencing hearings.

Among the hours of graphic footage, support worker Rogers is shown slapping patient Simon Tovey across the cheek before telling him: "Do you want a scrap? Do you want a fight? Go on and I will bite your bloody face off."

In a statement read outside court after the hearing, families of the abused patients said seeing the footage had been "distressing and extremely harrowing".

"The guilty parties were only charged with offences shown on the Panorama programme and it would be naive to believe that this monstrous behaviour had not been continuing for a very long time," they said.

Lawyers representing 17 families say they are now pursuing compensation in a civil action against Castlebeck, who owned Winterbourne View.

Defendant Jason Gardiner, who received a suspended jail term after admitting two charges of abuse, said he wanted to apologise for his actions.

"I take full responsibility for everything I have done," he said outside the court.

'Major flaws'

"It was a very difficult place to work, a tough place to work. We were under-staffed and working 12-hour days without a break.

"All I can do is apologise to everybody for what happened."

Sentencing Gardiner, Judge Ford had said he had heard he was "barely coping" with his remorse and regret.

James Welch, legal director of human rights campaign group Liberty, said he was "disappointed" with some of the sentences but thought the judge had been fair.

The home's owners, Castlebeck, said there had been "extensive changes in board and management" and new measures introduced to ensure it could not happen again.

The Care Quality Commission, which was heavily criticised after it ignored attempts by whistleblower Terry Bryan to inform them of the abuse that was happening at the home, said the responsibility for the abuse rested with the home's owners Castlebeck and individual employees.

Outgoing chair of the CQC, Dame Jo Williams said: "We are committed to do all we can to protect people whose circumstances make them vulnerable - and since the abuse at Winterbourne View was uncovered we have made changes to ensure that we are better placed to prevent abuse."

Care and Support minister Norman Lamb said: "This terrible case has revealed the criminal and inhuman acts some so-called care workers are capable of.

"It has also shone a light on major flaws in the system which we will address. We will publish our final recommendations very soon."

Sentences of all those found guilty are detailed below:

Wayne Rogers, 32, of Kingswood, jailed for two years after admitting nine charges of ill-treatment.

Alison Dove, 25, of Kingswood, was jailed for 20 months for seven counts of abuse;

Graham Doyle, 26, of Patchway, was jailed for 20 months for seven counts of abuse;

Nurse Sookalingum Appoo, 59, of Downend jailed for six months for wilfully neglecting patients;

Nurse Kelvin Fore, 33, from Middlesbrough, also jailed for six months for wilfully neglecting patients;

Holly Laura Draper, 24, of Mangotsfield, pleaded guilty to two charges of abuse and was jailed for 12 months;

Daniel Brake, 27, of Downend, pleaded guilty to two charges of abuse and was given a six month jail sentence suspended for two years and ordered to carry out 200 hours of unpaid work;

Charlotte Justine Cotterell, 22, from Yate, pleaded guilty to one charge of abuse and was given a four-month jail term suspended for two years. Cotterell was ordered to do 150 hours of unpaid work and complete 12 months supervision;

Michael Ezenagu, 29, from Shepherds Bush, west London, admitted two counts of abuse and was given a six month jail sentence suspended for two years and ordered to carry out 200 hours of unpaid work;

Neil Ferguson, 28, of Emerson Green, admitted one count of abuse and was given a six month jail term was suspended for two years and ordered to carry out 200 hours of unpaid work;

Jason Gardiner, 43, of Hartcliffe, who admitted two charges of abuse, was given a four month jail term was suspended for two years and ordered to carry out 200 hours of unpaid work.

The BBC is not responsible for the content of external sites.

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Winterbourne View: Care workers jailed for abuse

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Six out of 11 care workers who admitted a total of 38 charges of neglect or abusing patients at a private hospital are jailed.

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Reducing Health Inequalities Through New Models of Care - Interview with Michael Marmot

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Vanguards were introduced in 2015 as part of the NHS Five Year Forward View. The 50 chosen vanguards are tasked to develop new care models and potentially redesign the health and care system. It is envisaged that this could lead to better patient care, service access and a more simplified system.

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Our mission, with our partners, is to improve health and secure high-quality healthcare for the people of England, now and for future generations.

NHS England relies on numerous strategic partnerships at local and national level to deliver our business, and our partners rely on us to deliver theirs.

We collaborate and co-operate with organisations at national and local level to improve outcomes, meet the requirements of the mandate and ensure that the NHS operates within its financial resources.

NHS England supports and relies upon local healthcare professionals making decisions about services in partnership with their patients and communities. Our teams work closely with CCGs, GP practices, local authorities and Health and Wellbeing Boards.

The work of NHS England is supported by a number of national NHS and third-party organisations including NHS Digital, NHS Business Services Authority (NHS BSA), NHS Shared Business Services (NHS SBS), NHS Property Services Ltd. (NHSPS) and Primary Care Support England (PCSE) provided by Capita. Additionally, NHS England hosts NHS Interim Management and Support (NHS IMAS) and sponsors the Sustainability Unit on behalf of the NHS.

We strive for consistency and coherence in the way we manage our relationships with partners in order to deliver our ambitions in the NHS Long Term Plan. We will continue to ensure we engage proactively with key delivery partners.

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NHS England » Partnerships and relationships

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NHS England relies on numerous strategic partnerships at local and national level to deliver our business, and our partners rely on us to deliver theirs.

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The National Health Service explained | Guardian Explainers

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Visiting services is an important part of our inspection process. It gives us an opportunity to talk to staff and people who use services.

Carrying out site visits also allows us to observe care and to look at people's records to see how their needs are managed.

Types of inspection

We carry out regular checks on health and social care services. We call these comprehensive inspections and we use them to make sure services are providing care that's safe, caring, effective, responsive to people's needs and well-led.

Some things - such as how frequently we inspect, the size of the inspection team we use and whether or not we tell the service that we're coming - depend on what type of service we are inspecting.

We also carry out focused inspections. These are smaller in scale than comprehensive inspections, although they follow a similar process.

We carry out focused inspections for two reasons:

To look at something we're concerned about, which might have been raised during a comprehensive inspection or through our monitoring work.

If there is a change in a care provider's circumstances. This might mean they've been involved in a takeover, a merger or an acquisition.

A focused inspection does not always look at all five of our key questions. The size of the team and who's involved depend on what the inspection is looking at.

Inspecting different types of service

There are some differences between the things we look at when we inspect different types of service. For example, when we inspect NHS trusts we look at eight core services. When we inspect GP practices, we look at how the practice provides services to particular population groups. We apply our five key questions to each of these things.

What are core services?

What are population groups?

The start of the visit

At the start of the inspection, the inspector or inspection team usually meet senior staff. At this meeting, we will explain:

Who the inspection team are.

The scope and purpose of the inspection.

How we will communicate our findings.

Inspections of acute hospitals, GP practices and GP out-of-hours services begin with a presentation by the care provider, in which they give their own view of their performance.

Gathering evidence

The inspection team uses the key lines of enquiry and information from the planning stage to structure their visit and focus on areas of concern or areas where the service is performing particularly well. The team collects evidence against the key lines of enquiry by:

Gathering the views of people who use services. This includes:

Speaking to people individually and in groups.

Using comment cards placed in GP surgeries or busy areas in hospitals.

Staffing pop-up engagement stalls before NHS acute hospital trust inspections.

Using information gathered from complaints and concerns from people who use services.

Gathering information from staff.

Other inspection methods include:

Observing care.

Looking at individual care pathways.

Reviewing records.

Inspecting the places where people are cared for.

Looking at documents and policies.

Feedback

At the end of the visit, the inspector or senior members of the inspection team hold a feedback meeting with senior staff. At this meeting, the inspection team:

Gives a summary of what has been found during the visit.

Highlights any issues that have come up.

Identifies any action the service provider needs to take immediately.

Outlines any plans for further announced visits.

Explains how we will make our judgements and publish them.

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Visiting services is an important part of our inspection process. It gives us an opportunity to talk to staff and people who use services. Carrying out site visits also allows us to observe care and to look at people's records to see how their needs are managed.

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How Public Healthcare-NHS works in England

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NHS North East Hampshire and Farnham CCG

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Working together to provide health and social care locally

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Safeguarding adults in health and social care

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How does the NHS in England work? An alternative guide

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How economic inequality harms societies | Richard Wilkinson

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http://www.ted.com We feel instinctively that societies with huge income gaps are somehow going wrong. Richard Wilkinson charts the hard data on economic inequality, and shows what gets worse when rich and poor are too far apart: real effects on health, lifespan, even such basic values as trust.

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Original Article

†
Submitted August 2015.

The authors thank Antonio Rojas-Garcia for his help with the literature searching, Josie Dixon, Julian Le Grand and an anonymous referee for helpful comments, and Judith Payne for excellent copy-editing, though the authors take full responsibility for all remaining errors and omissions. Financial support is from an Economic and Social Research Council (ESRC) Professorial Fellowship to Propper (ES/J023108/1) and a National Institute for Health Research (NIHR) Senior Research Fellowship to Cookson (SRF-2013-06-015). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Abstract

This paper reviews what is known about socio-economic inequalities in health care in England, with particular attention to inequalities relative to need that may be considered unfair ('inequities'). We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups 'slight', inequalities of 5-15 per cent 'moderate' and inequalities of more than 15 per cent 'substantial'. Overall public health care expenditure is substantially concentrated on poorer people. At any given age, poorer people are more likely to see their family doctor, have a public outpatient appointment, visit accident and emergency, and stay in hospital for publicly-funded inpatient treatment. After allowing for current self-assessed health and morbidity, there is slight pro-rich inequity in combined public and private medical specialist visits but not in family doctor visits. There are also slight pro-rich inequities in overall indicators of clinical process quality and patient experience from public health care, substantial pro-rich inequalities in bereaved people's experiences of health and social care for recently deceased relatives, and mostly slight but occasionally substantial pro-rich inequities in the use of preventive care (for example, dental check-ups, eye tests, screening and vaccination) and a few specific treatments (for example, hip and knee replacement). Studies of population health care outcomes (for example, avoidable emergency hospitalisation) find substantial pro-rich inequality after adjusting for age and sex only. These findings are all consistent with a broad economic framework that sees health care as just one input into the production of health over the life course, alongside many other socio-economically patterned inputs including environmental factors (for example, living and working conditions), consumption (for example, diet and smoking), self-care (for example, seeking medical information) and informal care (for example, support from family and friends).

Policy points

Poorer and more socially disadvantaged people tend to consume more health care at any given age, in terms of both volume and cost, because they are sicker.

Richer and more socially advantaged people tend to present to health care providers at an earlier stage of illness and to consume more preventive care.

There are slight pro-rich inequities in some clinical process quality and patient experience measures but bigger inequities in some forms of preventive care and care involving substantial elements of co-payment and/or non-medical personal care.

There are substantial pro-rich inequalities in population health care outcomes (for example, potentially avoidable mortality and hospitalisation), but it is not known how far these reflect inadequate care rather than morbidity beyond the control of health and social services.

To address inequalities in health care, policymakers need better information about how local inequalities change over time in response to local policy changes, together with longitudinal analysis of health care inequalities over the life course.

I. Introduction

This paper reviews evidence on socio-economic inequalities in health care in England, a country that consistently comes near the top of international league tables of equity in health care financing. 1 Benefit incidence studies show that public health care expenditure in England disproportionately benefits poorer people. 2 However, this does not necessarily mean that health care is distributed fairly in relation to need, since poorer people tend to be sicker and so have greater need for health care. So our review pays close attention to empirical studies that have attempted to allow for need in order to assess how far socio-economic differences in health care may be considered unfair or inequitable.

Associated with these policy goals is a large literature on the distribution of health care and of health in the UK and England. In this review, we confine our attention primarily to the literature on inequalities that takes an economics perspective. Under this umbrella, we focus mainly on health care and present studies of departures from equality in health care supply, utilisation, expenditure and quality. We also devote some space to recent literature on inequality in patient experience and outcomes. We do not review evidence of inequality in health care financing since the NHS is largely funded through general taxation and few people in England report financial difficulties in paying health care bills or face catastrophic medical expenditures. 7

We focus on variations in health care associated with socio-economic characteristics related to ability to pay, such as income, education, deprivation and social class, although there is also evidence of social inequality by other individual characteristics such as ethnicity, 8 geographical location, 9 age, 10 gender, 11 veteran status, 12 type of illness 13 and other aspects of disadvantage or vulnerability. 14 As shorthand, we use the term 'poor' in a broad sense to mean 'socio-economically disadvantaged'.

We update previous reviews of studies of health care inequalities in England published in the 1990s and early 2000s 15 by identifying major national studies conducted subsequently. We also draw on major cross-country studies and reviews of evidence in the US. 16 However, our aim is to identify stylised facts about health care inequalities rather than to conduct a systematic review of this large, diverse and multidisciplinary empirical literature.

We start by reviewing general population studies that aim to provide a comprehensive picture of inequality in the health care sector as a whole, across a broad range of different clinical conditions. We then include a selection of recent national studies of inequalities in services for specific clinical conditions, which are reasonably representative of the literature. We focus on three common and high-profile conditions: cancer, circulatory disease and osteoarthritis. Cancer and circulatory disease are policy priorities due to their high mortality rates and cost, and osteoarthritis is a policy priority due to long hospital waiting times for hip and knee joint replacement. We also present selected studies of preventive services such as screening for cervical cancer, which are particularly prone to pro-rich inequality for reasons to do with health production that are explained in Section 'Equity studies and the health production approach'. We do not review studies of inequality in long-term care, such as home care and residential nursing home services for the elderly. In England, public funding for long-term care is means tested and services are organised separately from the NHS as part of local government social care services.

Almost all the evidence we cite focuses on publicly-funded NHS health care, since data on privately-funded health care are generally not available from routine administrative data and only sometimes included in survey data. This is a limitation, since privately-funded care makes up a substantial proportion of elective hospital care for low-risk procedures and some forms of preventive care such as diagnostic tests and dentistry. Furthermore, important non-medical forms of prevention are privately funded - for example, housing quality, food quality and gym memberships.

Wherever possible, we seek to cite simple measures of relative inequality that are easy to compare across studies of different kinds of health care, such as relative gaps between the most and least socio-economically disadvantaged quintile groups of people in England. We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups 'slight', inequalities of 5-15 per cent 'moderate' and inequalities of more than 15 per cent 'substantial'. These criteria are arbitrary, but at least they are explicit and help us to achieve a degree of consistency in our conclusions about the size of different inequalities. Even this simple classification is not always possible, however, since there is substantial reporting diversity in the literature. For example, much of the health economics literature only reports concentration indices, which are hard to interpret, and much of the health services research literature only reports odds ratios from logistic regression, which - unlike rate ratios and relative risks - can be misleading without knowledge of baseline risks. 17 To facilitate comparison of the magnitude of inequality between different studies, we therefore recommend that future studies report marginal effects, as well as or instead of concentration indices and odds ratios, so that readers can calculate absolute differences between social groups allowing for covariates. There is also reporting diversity due to different units of analysis (for example, individual, household, small area, large area), different data sources (for example, whole-population administrative data versus sample survey data) and different methods of adjusting for need (for example, direct versus indirect standardisation and different sets of need variables). Another key limitation is that the vast majority of studies continue to be snapshots of a particular population at a particular point in time rather than comparative studies. Few studies compare health care equity in England at different points in time, few compare England with other countries and, so far, none has performed detailed comparisons of socio-economic equity in health care between different local areas of England. This makes it hard to draw conclusions about how far inequities are changing over time, how well England is performing on equity in health care compared with other countries, and whether some areas of England are succeeding better than others at tackling health care inequities.

Finally, almost all the empirical research focuses on health care received during a particular period rather than over the course of individual lifetimes. This absence of a lifetime perspective means that issues such as poor health leading to low incomes, or low incomes leading to later poor health, are not addressed by studies that focus on whether care currently is allocated according to current need or whether this allocation favours the currently poor or the currently rich.

II. Equity studies and the health production approach

We begin by outlining how socio-economic inequalities in health care fit into the broader economic approach that treats health care as one of many inputs into the production of individual health. The approach was introduced by Grossman ( 1972) and focuses on adult health, taking income as given. 18 The basic insight was that health care is an input into a production process rather than a final good. Medical treatment itself is often time-consuming and unpleasant, i.e. more like a 'bad' than a 'good'. What an individual values as a final good is health. Health demand consists of two elements. The first is a consumption effect: health yields direct utility, i.e. individuals feel better when they are healthier. The second is an investment effect (and the novel part of the model): that health increases the number of days available to participate in market and non-market activities.

In a simple production function approach, focusing on adult health under conditions of certainty, individuals get utility from a composite consumption good, Z, and their health stock, H, which depreciates over time, t, at a rate δ:

(1)

(2)

where s is a vector of tastes and I is investment in health. The household production function for health is

(3)

and that for consumption goods is

(4)

where M is a vector of market inputs including medical care, TH is time spent on improving health, E is a vector of factors that affect the production function, including education and environment, X is a vector of market-produced goods and TC is time spent on the composite consumption good. 19

While the basic model is not primarily focused on the issue of socio-economic inequalities in health (and ignores any causal link between health and future income), its components make clear that departures from the allocation of current health care according to current need may arise for (at least) two different types of reason.

First, individuals will vary in their taste for health and consumption. Variation in taste means individuals will choose different levels of investment in health (including medical care) depending on their tastes as well as their resource constraints. This is not necessarily inequitable.

Second, health involves many inputs. Other inputs into health production include health-related consumption such as diet, physical activity, smoking, drinking and narcotic use. The ability to produce health from a given set of inputs will depend on the individual's knowledge (education) and the environment they face, including health-related factors such as living and working conditions, stressful aspects of the social and economic environment, air pollution, noise pollution, water pollution, transport safety and violent crime. Thus even if health care prices are set to zero, there are many other factors that may lead to socio-economic inequality in health and in the receipt of health care. First, poorer (more socio-economically disadvantaged) individuals will have fewer resources (wealth, human capital, social capital) to invest in the production of health. Thus a unit of medical care will be less beneficial than for a richer individual who will have more resources to utilise alongside that medical care. Second, the nature of a low-income individual's employment and life may also mean they are heavily time-constrained. If so, this will raise the relative prices of time inputs for them and they may therefore value the opportunity costs from using health care (for example, time away from domestic and work duties, travel costs) more highly than the potential health gains, particularly when considering investments in health such as preventive care. Thus poorer individuals may tend to use less preventive health care when facing no immediate pain or disability, and present to health care providers at a later stage of illness. This will mean that when they finally access health care, they will be in greater need and require more health care inputs. Third, the quality of care received may depend in part upon the intensity and effectiveness of care-seeking behaviour - for example, in navigating through a complex health care system and lobbying providers for the best-quality care. Again, individuals with fewer resources will be less equipped to undertake such activity. All these reasons mean that we would expect, even in a system with zero monetary prices, to see poorer individuals having a greater need for care and requiring more health care relative to that need. To the extent that measures of inequities do not take into account the resources required by the individual to use health care inputs, they will present an overly positive picture of inequities in the receipt of care.

III. Measuring inequities in health care

To measure departures from horizontal equity, the basic research strategy is to measure cross-sectional associations between a socio-economic variable (for example, income) and a health care variable (for example, doctor visits) after adjusting for 'appropriate' or 'fair' differences due to differences in individual needs and, in some cases, preferences. 25 This is methodologically challenging for several reasons.

Ascertaining the appropriate magnitude of adjustment for 'fair' differences requires a potentially contestable normative assumption about how far people with different needs and preferences should be treated differently. 26 This is an assumption about 'vertical equity' - the appropriately different treatment of people who differ in relevant respects. Except in rare cases where it is reasonable to assume that all individuals have identical needs and preferences for health care, it is not possible to measure horizontal equity in health care without making a normative assumption about vertical equity. The simplest and most common vertical equity assumption is that the current population average relationship between need and utilisation is appropriate (i.e. 'on average, the system gets it right'). This assumption implies that need adjustment should be performed by estimating needed health care using population average reference values of non-need characteristics. An alternative assumption is that the need-utilisation relationship among socio-economically advantaged individuals is appropriate (i.e. 'the system gets it right for socio-economically advantaged patients'). Different vertical equity assumptions involving different reference values are also possible, as are assumptions based on expert opinion about what the need-utilisation relationship should ideally be, rather than on data on what it currently is. 27

Another limitation of general household survey data is that small sample sizes preclude studies of inequalities in the use of specific health care technologies for specific conditions. 31 Although administrative data have larger sample sizes, they have limited measures of ability to pay. For example, UK administrative data on health do not include measures of patient or household ability to pay and have not been matched to other administrative data that provide such measures, such as tax records. The approach taken in all administrative data studies in England is to proxy ability to pay by measures of the socio-economic status of the population of the area in which the patient lives. Most studies in England since 2001 have used variants of the 'Index of Multiple Deprivation' based on just over 32,000 English small-area neighbourhoods of approximately 1,500 people (minimum 1,000 and maximum 3,000) that were introduced in the 2001 Census. Area deprivation is correlated with individual socio-economic status, due to house price differentials and wealth-related housing segregation. However, the correlation is imperfect - rich individuals may live in deprived areas and poor individuals may live in non-deprived areas. Furthermore, there are potential biases due to migration and consequent change in the individual-level composition of areas over time.

Another challenge is heterogeneity in needs and preferences between individuals. This can mean, for example, that the degree of horizontal inequity may vary between groups of individuals. 32, 33 So an overall estimate of horizontal inequity that aggregates across different types of patient without explicitly modelling the interactions between need, preferences and socio-economic status may suffer from a composition effect. Finally, almost all analyses to date take current income and need (however defined) as given and have examined departures from equity at one point in time. If there is pro-rich inequality at all ages, then a cross-sectional snapshot will underestimate the extent to which health care is pro-rich. More broadly, they do not take into account the dynamic relationship between health and ability to pay.

As a result of these methodological challenges, it is often hard to draw clear normative conclusions about 'horizontal inequity' as opposed to positive conclusions about inequality.

IV. Findings

1. General population studies of the whole health care sector

Most economic studies focus on the general population and seek to provide a comprehensive picture of health care inequality across the health care sector as a whole. We review general population studies under three categories: (a) health care quantity (including supply, utilisation and expenditure), (b) health care quality (including process quality and patient experience) and (c) health care outcomes.

a) Health care quantity

Table 1 summarises selected recent national studies of socio-economic inequality in overall health care supply, utilisation and expenditure in England.

NHS inpatient hospital costs (including emergency) [admin data]

2010-11 to 2014-15

None

Substantial pro-poor inequality, e.g. relative gap of 35% between most and least deprived fifths of patients aged 65 and over (£5,605 vs £4,146)

Kelly, Stoye and Vera-Hernández, this issue

One survey study found no significant income-related or education-related inequality in day-case and inpatient hospital utilisation after allowing for need during the short window 1998-2000. 41 However, a study using administrative data at small-area level for 2000-08 found significant 'pro-poor' inequality in both outpatient and non-emergency inpatient hospital care in each year of the period, after allowing for available small-area measures of need such as population size, age-sex structure and disease prevalence from primary care pay-for-performance disease registries. 42

Analysis of health care expenditure in England requires administrative data, since survey respondents are not billed for their NHS care and do not know how much it costs. Two recent studies have examined the socio-economic distribution of hospital expenditure using whole-population hospital administrative data. Both find that hospital expenditure is substantially concentrated on poorer people. Kelly, Stoye and Vera-Hernández (this issue) find a relative gap of 35 per cent between the most and least deprived fifths of patients aged 65 and over (£5,605 versus £4,146). Asaria, Doran and Cookson ( 2016) find a relative gap of 31 per cent between the most and least deprived fifths of all-age population (£597 versus £455).

b) Health care quality

Table 2 summarises recent national studies of socio-economic inequality in both the quality and outcomes of health care.

Primary care process quality [QOF admin data] a

2004-05 to 2011-12

None b

Slight pro-rich inequity (4%) reducing over time

Asaria, Ali et al., 2016

Proportion of people feeling supported to manage their condition [GP Patient Survey]

2012 to 2014

None b

Moderate pro-rich inequity, e.g. most deprived fifth 10 percentage points lower than least deprived fifth

Department of Health, 2015

Patient-rated experience of NHS services [GP Patient Survey]

2012 to 2014

None b

Slight pro-rich inequity, e.g. percentage point gaps between most and least deprived fifths of 4.7 (GP services), 3 (out-of-hours GP services) and 4 (dental services)

Department of Health, 2015

Patient-rated access to NHS services [GP Patient Survey]

2012 to 2014

None b

Slight pro-rich inequity, e.g. percentage point gaps between most and least deprived fifths of 5 (GP services) and 3 (dental services)

Department of Health, 2015

In the UK, in contrast with the US, 43 the study of inequalities in health care quality is relatively recent. Arguably, as quality is measured for patients who are already receiving care, it is less necessary to standardise for need in such studies.

There has been an increase in the availability of measures of quality of care in the UK since the early 2000s. The UK primary care pay-for-performance scheme introduced in 2004-05 includes data on practice-level primary care clinical process quality for a number of different conditions. One study examined an average of these scores and found a gap of 4 per cent between the most deprived and least deprived fifth of practices in 2004-05, which fell to 0.8 per cent in 2006-07. 44 A more recent study updated this analysis to 2011-12 and found ongoing inequality reductions. 45

The UK Department of Health recently reported a series of estimates of the difference in health care patient experience at small-area level, based on data from the annual national GP Patient Survey. 46 Characterising small areas by deprivation, it found pro-rich differences between the top and bottom deprivation quintile groups in the proportion of people feeling supported to manage their condition, in patient-rated experience of GP services and NHS dental services and in patient-rated access to GP and dental services. 47

Finally, a recent study of equity in palliative care used data from the 2013 National Survey of Bereaved People and found substantial pro-rich inequalities in bereaved people's experiences of care for a recently deceased close relative - for example, in the probability of rating the overall quality of care as 'outstanding' or 'excellent', in the probability of receiving as much support as needed from health and social services and in the probability of dying at home. 48

c) Health care outcomes

To date, most studies of socio-economic inequality in overall health care outcomes have been conducted at population level and have adjusted for age and sex but not for morbidity and other risk factors beyond the immediate control of health care providers. One study of administrative data from 2004-05 to 2011-12, for example, found substantial pro-rich inequality in both avoidable emergency hospitalisation and mortality amenable to health care, which reduced slightly during the period. 49 However, we cannot draw conclusions about how far these pro-rich inequalities are 'unfair' inequalities attributable to inadequate health care, as opposed to worse health among poorer populations attributable to wider health production processes.

Patient-level studies of health care outcomes can control more accurately for morbidity and other individual-level risks of poor health care outcomes that are beyond the immediate control of health care providers. A limitation, however, is that patient-level studies focus on patients who have succeeded in getting access to health care and so may give a selective picture of inequalities in the general population - including outcomes for people who do not receive appropriate care. Furthermore, morbidity at the point of treatment may partly be due to inadequate health care in past years. A longitudinal perspective on fairness in health care would therefore need to allow for the dynamic relationship between health care and morbidity and not merely treat current morbidity as an exogenous risk factor.

2. Condition-specific studies of specific sub-populations

In this subsection, we review a selection of recent national studies of inequalities in services for specific clinical conditions. One of the advantages of the condition-specific approach is that there is less heterogeneity in need within conditions than across conditions. However, there is no reason to expect no heterogeneity nor that this heterogeneity is not socially graded.

Re-operation rates [admin data]

2000 to 2008

Age, sex, co-morbidity

More deprived patients more likely to require re-operation following bowel cancer surgery

Burns et al., 2011

Survival rates [admin data]

1974 to 2004

Age, sex

Pro-rich inequality for rectal and breast cancer

Lyratzopoulos et al., 2011

a) Cancer

It is well established that even in England, where the monetary price of care is zero, poorer patients tend to present at a later stage of cancer. For example, using data from 1998 to 2000, one study found that patients in the least deprived fifth of neighbourhoods are more likely to be diagnosed with breast cancer at early stage I (39.2 per cent versus 36.3 per cent) and less likely to be diagnosed at advanced stage IV (5.0 per cent versus 7.0 per cent). 53 Poorer patients are also more likely to be admitted as emergencies. A study using data from 1999 to 2006 found that cancer patients from the most deprived fifth of neighbourhoods in England are more likely to be admitted to hospital as emergencies than those from the least deprived fifth (colorectal cancer 37.9 per cent versus 28.9 per cent, breast cancer 17.0 per cent versus 10.7 per cent and lung cancer 55.2 per cent versus 48.3 per cent). 54 The same study also found that deprived patients are less likely to receive the preferred surgical procedures for these cancers. It is not known how far these patterns reflect differences in care-seeking behaviour and late presentation, as opposed to poorer-quality care for patients of lower socio-economic status (SES).

b) Circulatory disease

In contrast to cancer treatment, several recent studies of circulatory disease have found fewer differences across SES groups. One study using Health Survey for England data from 2003 and 2006 found pro-rich inequalities in outpatient visits, electrocardiography tests and heart surgery. 58 Another study, using practice-level administrative data from 2006-07, found that practices serving more deprived populations were less likely to prescribe statins (a cholesterol-lowering medication) for primary prevention of cardiovascular disease in low-risk patients. 59 However, a patient-level study using follow-up data for 2005-07 from the Whitehall study of civil servants found no socio-economic difference in use of cholesterol-lowering medication related to employment grade. 60 Furthermore, studies looking at secondary prevention following cardiovascular events or diagnosis in higher-risk patients have found no pro-rich inequities. Using patient-level clinical registry data from 1995 to 2005, one study found no deprivation-related difference in secondary prevention after stroke. 61 Another study using patient-level clinical registry data found no deprivation-related inequities in medical treatments for patients following heart attack or with chronic angina or requiring secondary prevention. 62 After controlling for available measures of need, a study using data from 1985 to 1999 found no association between social position and the use of cardiac procedures or secondary prevention drugs. 63 Finally, a small-area study using data from 2001 to 2008 also found no clear evidence of inequality in coronary revascularisation procedures favouring people living in less deprived neighbourhoods. 64, 65

c) Hip and knee joint replacement for osteoarthritis

Finally, a recent study using patient-level administrative data found evidence of deprivation-related inequalities in patient-reported outcome measures after hip and knee replacement surgery from 2009 to 2011. 77 These inequalities were attenuated but not eliminated by adjusting for risk in the form of pre-operative health and disease severity. However, the adjusted differences were small: absolute differences between top and bottom deprivation fifths of 2.8 and 2.4, on a scale of 0 to 48, respectively for hip replacement (Oxford Hip Score) and knee replacement (Oxford Knee Score).

d) Preventive care

Table 4 summarises selected recent national studies of socio-economic inequality in preventive care, including dental check-ups, eye tests and condition-specific studies of adult screening and childhood vaccination.

Bowel cancer follow-up testing after initial screening shows there may be cancer [admin data]

2006 to 2009

Slight pro-rich inequity: least deprived fifth 3.5% more likely to attend follow-up colonoscopy than most deprived fifth (levels of 89.5% and 86.4%)

Morris et al., 2012

Human papilloma virus (HPV) cervical cancer vaccine [admin data]

2008-09 to 2010-11

No pro-rich inequity: deprivation-related differences in 2007-08 pilot disappeared by 2008-09, but ethnicity-related inequities remained

Fisher et al., 2014

Preventive care inequalities are pervasive and can be substantial, as one would expect from a health production perspective in so far as poorer individuals are less able and willing to invest in health. 78 In addition, neither dental check-ups nor eye tests are universally funded by the NHS, though there are various age- and means-related subsidies. 79

Most condition-specific studies of equity in preventive care focus on screening and vaccination programmes that target particular 'at-risk' sub-populations. The measurement of need is relatively straightforward in studies of this kind, in so far as everyone in a particular age-sex group is considered to need the service in question. For example, the national bowel cancer screening programme in England currently recommends and offers colonoscopy and stool examination screening for colon cancer to all men and women between the ages of 60 and 75 years. 80

In general, poorer and less-educated patients are less likely to participate in adult screening programmes. For example, in the early stages of the NHS bowel cancer screening programme from 2006 to 2009, there were substantial differences in uptake between people living in the most and least deprived fifth of neighbourhoods in England of 35 per cent versus 61 per cent. 81 Even following positive screening results, people living in the most deprived fifth of neighbourhoods were still a little less likely to attend appointments for further diagnostics and treatment. 82 Children from poor families are also less likely to participate in childhood vaccination programmes. For example, coverage of the measles, mumps and rubella (MMR) vaccine during the 1990s was lower in the most deprived fifth of neighbourhoods of England than in the least deprived fifth (86 per cent versus 92 per cent in 1992 and 85 per cent versus 87 per cent in 2001). 83 Interestingly, this inequality subsequently reversed in the mid 2000s following adverse press coverage of the MMR vaccination, as parents from more affluent neighbourhoods responded more negatively to this media coverage. Socio-economic inequality was also found in uptake of human papilloma virus (HPV) cervical cancer vaccine during pilots in the financial year 2007-08. 84 This was found to disappear in the subsequent national roll-out, though ethnic inequalities remained from 2008-09 to 2010-11. 85

These findings are mirrored in other high-income countries. A recent study of 13 European countries excluding England found pro-rich and pro-educated inequities in breast and colon cancer screening, blood tests and flu vaccination using data from the Survey of Health, Ageing and Retirement in Europe pooled across three survey waves around 2004, 2007 and 2009. 86 Data from the British Household Panel Survey suggest that participation in courses leading to qualifications increases the probability of having a smear test by between 4.3 and 4.4 percentage points. 87 The WHO World Health Survey of 70 countries in 2002-03 found slight to moderate pro-rich inequity in cervical cancer screening for women aged 25-64 in 50 out of the 67 countries with screening data 88 and pro-educated inequity pooling across all 22 of the participating European countries including the UK. 89 While the latter finding was not statistically significant within the UK alone, the sample was small (521 women). A larger study of 3,185 women aged 40-74 in 2005-07 did find statistically significant educational and ethnic inequities in cervical screening. 90

V. Discussion

Our review suggests the following stylised facts about the socio-economic distribution of health care, after some kind of adjustment for need, in England:

1. Poorer individuals consume a greater quantity of publicly-funded NHS health care in terms of overall expenditure and utilisation.

2. Richer patients tend to achieve better health care outcomes (for example, surgical mortality or preventable hospitalisation) even after adjusting for observable risk factors.

3. Richer individuals tend to present to health care providers at an earlier stage of disease progression; consume more medical specialist visits including privately-funded visits; consume more preventive NHS care such as screening and vaccination services; are more likely to receive a needed NHS hip or knee replacement operation and to be referred by their doctor for specialist investigation of hip pain; have shorter waiting times for heart bypass surgery and angioplasty; may receive slightly better NHS quality of care for some conditions as measured by clinical process quality indicators; and report slightly better patient experiences.

The picture is thus one of an overall pro-poor distribution of quantity but a pro-rich distribution of quality, experience and access to services including waits for treatment. However, in terms of magnitude, the pro-rich inequity gaps are generally slight (5 per cent or less) and it is unusual to find a need- or risk-adjusted gap of greater than 10 per cent between the richest and poorest fifths. Furthermore, studies rarely provide detailed information about how far these pro-rich inequities are attributable to the behaviour of NHS health care providers as opposed to socio-economic differences in health care-seeking and self-care behaviour. We therefore recommend that future studies report marginal effects, as well as or instead of concentration indices and odds ratios, so that readers can calculate absolute differences between social groups allowing for covariates.

These stylised facts make sense in the context of a health production approach where health care is only one input into health and the costs of other inputs differ systematically with income. Individuals who have fewer resources will tend to have worse health at all stages of life. This helps to explain fact (1), since people with worse health need more health care and generally demand more health care in a universal health system such as the English NHS, which sets prices at or close to zero. It also helps to explain fact (2), since people with worse health are at risk of worse health care outcomes. It also helps rationalise the set of facts under point (3). Poorer individuals invest less time and money in improving their health because they have fewer resources to invest, face higher opportunity costs in terms of lost income and household production relative to their limited resources, and may value future health benefits less if they have a higher rate of time preference. 91

Finally, as is clear from this review, most of the research on whether health care is allocated according to need has focused on appropriate adjustment for need, taking resources as given. But to the extent that ill health drives both health and socio-economic factors, particularly employment, earnings and income, it is no surprise that the poor use more health care. A life-cycle perspective, in which attention is given to the relationship between income and need, will allow a fuller assessment of the extent to which this is inequitable.

1. 1

2. 2
Kelly, Stoye and Vera-Hernández, this issue.

3. 16

4. 19
This basic model has been extended to incorporate uncertainty (Dardanoni and Wagstaff, 1990), which is central to certain forms of health care such as screening and diagnosis that are essentially about reducing uncertainty, and to incorporate pre-adulthood stages of life. Current models of health and human capital development during the early years of life emphasise (1) the role of in utero nutrition and physiological development on outcomes in later life and (2) the role of families and childhood environments in shaping skills and character traits that influence both income and health in later life (Fogel, 2003; Heckman, 2012; Galama and van Kippersluis, 2013; Almond, Currie and Meckel, 2014; Heckman and Mosso, 2014).

5. 30
Sen, 2002a; Bago d'Uva et al., 2008; Bago d'Uva, Jones and van Doorslaer, 2009; Johnston, Propper and Shields, 2009; Johnston et al., 2010.

6. 33
For example, there might be substantial horizontal inequity between rich and poor patients with mildly elevated blood pressure (a 'low' level of need) but no horizontal inequity among patients with severe heart disease (a 'high' level of need).

7. 40
Van Doorslaer et al., 2000; van Doorslaer, Koolman and Jones, 2004; van Doorslaer, Masseria and Koolman, 2006; Bago d'Uva, Jones and van Doorslaer, 2009; Devaux and de Looper, 2012; Devaux, 2015.

8. 68

9. 76
The overall growth in inpatient utilisation of heart surgery (coronary artery bypass grafting, CABG) was around 35 per cent whereas the reduction in waiting times for CABG was nearly 70 per cent. Waiting times for CABG fell from around 160 days to around 50 days.

10. 80
Data on individual health could, in principle, provide further useful information about need within such groups. For example, a person aged 60 with particular risk factors such as a family history of colon cancer may be considered to need screening more than another person of the same age without those risk factors.

Ancillary

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DOI

10.1111/j.1475-5890.2016.12109

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© 2016 The Authors. Fiscal Studies published by John Wiley & Sons Ltd. on behalf of Institute for Fiscal Studies

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Keywords

health care;

inequalities;

socio-economic factors;

I14;

I18

Publication History

Issue online:

Version of record online:

Funded by

Economic and Social Research Council. Grant Number: ES/J023108/1

National Institute for Health Research. Grant Number: SRF-2013-06-015

References

Agency for Healthcare Research and Quality (2014), 2014 National Healthcare Quality and Disparities Report, Rockville, MD.

Asaria, M., Ali, S. et al. (2016), 'How a universal health system reduces inequalities: lessons from England', Journal of Epidemiology & Community Health, doi:10.1136/jech-2015-206742.

Asaria, M., Doran, T. and Cookson, R. (2016), 'The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation', Journal of Epidemiology & Community Health, doi: 10.1136/jech-2016-207447.

Department of Health (2000), The NHS Plan: A Plan for Investment, a Plan for Reform.

Department of Health (2012), 'Health and Social Care Act 2012: fact sheets', http://www.dh.gov.uk/health/2012/06/act-explained/.

Department of Health (2015), NHS Outcomes Framework: Indicators for Health Inequalities Assessment.

Devaux, M. and de Looper, M. (2012), 'Income-related inequalities in health service utilisation in 19 OECD countries, 2008-2009', OECD Health Working Paper no. 58, doi:10.1787/5k95xd6stnxt-en.

Dixon, J., King, D., Matosevic, T., Clark, M. and Knapp, M. (2015), Equity in the Provision of Palliative Care in the UK: Review of Evidence, https://www.mariecurie.org.uk/globalassets/media/documents/policy/campaigns/equity-palliative-care-uk-report-full-lse.pdf.

Forde, I., Chandola, T., Raine, R., Marmot, M. G. and Kivimaki, M. (2011), 'Socioeconomic and ethnic differences in use of lipid-lowering drugs after deregulation of simvastatin in the UK: the Whitehall II prospective cohort study', Atherosclerosis, vol. 215, pp. 223-8.

Institute of Medicine (2001), Crossing the Quality Chasm: A New Health System for the 21st Century, Washington DC: National Academy Press.

OECD (2014), OECD Health Data. Available at http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.

Schoen, C. and Osborn, R. (2010), The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries, http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2010/nov/int-survey/pdf_2010_ihp_survey_chartpack_11182010_final_white_bkgd.pdf.

World Health Organisation (2000), The World Health Report 2000: Health Systems - Improving Performance.

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Original Article

†
Submitted August 2015.

The authors thank Antonio Rojas-Garcia for his help with the literature searching, Josie Dixon, Julian Le Grand and an anonymous referee for helpful comments, and Judith Payne for excellent copy-editing, though the authors take full responsibility for all remaining errors and omissions. Financial support is from an Economic and Social Research Council (ESRC) Professorial Fellowship to Propper (ES/J023108/1) and a National Institute for Health Research (NIHR) Senior Research Fellowship to Cookson (SRF-2013-06-015). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Abstract

This paper reviews what is known about socio-economic inequalities in health care in England, with particular attention to inequalities relative to need that may be considered unfair ('inequities'). We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups 'slight', inequalities of 5-15 per cent 'moderate' and inequalities of more than 15 per cent 'substantial'. Overall public health care expenditure is substantially concentrated on poorer people. At any given age, poorer people are more likely to see their family doctor, have a public outpatient appointment, visit accident and emergency, and stay in hospital for publicly-funded inpatient treatment. After allowing for current self-assessed health and morbidity, there is slight pro-rich inequity in combined public and private medical specialist visits but not in family doctor visits. There are also slight pro-rich inequities in overall indicators of clinical process quality and patient experience from public health care, substantial pro-rich inequalities in bereaved people's experiences of health and social care for recently deceased relatives, and mostly slight but occasionally substantial pro-rich inequities in the use of preventive care (for example, dental check-ups, eye tests, screening and vaccination) and a few specific treatments (for example, hip and knee replacement). Studies of population health care outcomes (for example, avoidable emergency hospitalisation) find substantial pro-rich inequality after adjusting for age and sex only. These findings are all consistent with a broad economic framework that sees health care as just one input into the production of health over the life course, alongside many other socio-economically patterned inputs including environmental factors (for example, living and working conditions), consumption (for example, diet and smoking), self-care (for example, seeking medical information) and informal care (for example, support from family and friends).

Policy points

Poorer and more socially disadvantaged people tend to consume more health care at any given age, in terms of both volume and cost, because they are sicker.

Richer and more socially advantaged people tend to present to health care providers at an earlier stage of illness and to consume more preventive care.

There are slight pro-rich inequities in some clinical process quality and patient experience measures but bigger inequities in some forms of preventive care and care involving substantial elements of co-payment and/or non-medical personal care.

There are substantial pro-rich inequalities in population health care outcomes (for example, potentially avoidable mortality and hospitalisation), but it is not known how far these reflect inadequate care rather than morbidity beyond the control of health and social services.

To address inequalities in health care, policymakers need better information about how local inequalities change over time in response to local policy changes, together with longitudinal analysis of health care inequalities over the life course.

I. Introduction

This paper reviews evidence on socio-economic inequalities in health care in England, a country that consistently comes near the top of international league tables of equity in health care financing. 1 Benefit incidence studies show that public health care expenditure in England disproportionately benefits poorer people. 2 However, this does not necessarily mean that health care is distributed fairly in relation to need, since poorer people tend to be sicker and so have greater need for health care. So our review pays close attention to empirical studies that have attempted to allow for need in order to assess how far socio-economic differences in health care may be considered unfair or inequitable.

England's tax-funded National Health Service (NHS) provides a relatively generous package of health care, free at the point of use, which makes up nearly 85 per cent of national health care expenditure. Whilst the level of public funding is high, however, England is not an outlier. All high-income countries offer their citizens a substantial package of publicly-funded health care, including countries with relatively low shares of public expenditure on health such as the US and Chile, which spend just under 50 per cent compared with the OECD average of 73 per cent in 2012. 3 While all health care systems in wealthy countries have equity goals relating to access to, and/or delivery of, health care as well as its financing, 4 the English NHS is unusual in also having explicit policy objectives relating to reducing inequalities in health care outcomes. These objectives were first articulated in 2000 5 and formalised in the 2012 Health and Social Care Act. 6

Associated with these policy goals is a large literature on the distribution of health care and of health in the UK and England. In this review, we confine our attention primarily to the literature on inequalities that takes an economics perspective. Under this umbrella, we focus mainly on health care and present studies of departures from equality in health care supply, utilisation, expenditure and quality. We also devote some space to recent literature on inequality in patient experience and outcomes. We do not review evidence of inequality in health care financing since the NHS is largely funded through general taxation and few people in England report financial difficulties in paying health care bills or face catastrophic medical expenditures. 7

We focus on variations in health care associated with socio-economic characteristics related to ability to pay, such as income, education, deprivation and social class, although there is also evidence of social inequality by other individual characteristics such as ethnicity, 8 geographical location, 9 age, 10 gender, 11 veteran status, 12 type of illness 13 and other aspects of disadvantage or vulnerability. 14 As shorthand, we use the term 'poor' in a broad sense to mean 'socio-economically disadvantaged'.

We update previous reviews of studies of health care inequalities in England published in the 1990s and early 2000s 15 by identifying major national studies conducted subsequently. We also draw on major cross-country studies and reviews of evidence in the US. 16 However, our aim is to identify stylised facts about health care inequalities rather than to conduct a systematic review of this large, diverse and multidisciplinary empirical literature.

We start by reviewing general population studies that aim to provide a comprehensive picture of inequality in the health care sector as a whole, across a broad range of different clinical conditions. We then include a selection of recent national studies of inequalities in services for specific clinical conditions, which are reasonably representative of the literature. We focus on three common and high-profile conditions: cancer, circulatory disease and osteoarthritis. Cancer and circulatory disease are policy priorities due to their high mortality rates and cost, and osteoarthritis is a policy priority due to long hospital waiting times for hip and knee joint replacement. We also present selected studies of preventive services such as screening for cervical cancer, which are particularly prone to pro-rich inequality for reasons to do with health production that are explained in Section 'Equity studies and the health production approach'. We do not review studies of inequality in long-term care, such as home care and residential nursing home services for the elderly. In England, public funding for long-term care is means tested and services are organised separately from the NHS as part of local government social care services.

Almost all the evidence we cite focuses on publicly-funded NHS health care, since data on privately-funded health care are generally not available from routine administrative data and only sometimes included in survey data. This is a limitation, since privately-funded care makes up a substantial proportion of elective hospital care for low-risk procedures and some forms of preventive care such as diagnostic tests and dentistry. Furthermore, important non-medical forms of prevention are privately funded - for example, housing quality, food quality and gym memberships.

Wherever possible, we seek to cite simple measures of relative inequality that are easy to compare across studies of different kinds of health care, such as relative gaps between the most and least socio-economically disadvantaged quintile groups of people in England. We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups 'slight', inequalities of 5-15 per cent 'moderate' and inequalities of more than 15 per cent 'substantial'. These criteria are arbitrary, but at least they are explicit and help us to achieve a degree of consistency in our conclusions about the size of different inequalities. Even this simple classification is not always possible, however, since there is substantial reporting diversity in the literature. For example, much of the health economics literature only reports concentration indices, which are hard to interpret, and much of the health services research literature only reports odds ratios from logistic regression, which - unlike rate ratios and relative risks - can be misleading without knowledge of baseline risks. 17 To facilitate comparison of the magnitude of inequality between different studies, we therefore recommend that future studies report marginal effects, as well as or instead of concentration indices and odds ratios, so that readers can calculate absolute differences between social groups allowing for covariates. There is also reporting diversity due to different units of analysis (for example, individual, household, small area, large area), different data sources (for example, whole-population administrative data versus sample survey data) and different methods of adjusting for need (for example, direct versus indirect standardisation and different sets of need variables). Another key limitation is that the vast majority of studies continue to be snapshots of a particular population at a particular point in time rather than comparative studies. Few studies compare health care equity in England at different points in time, few compare England with other countries and, so far, none has performed detailed comparisons of socio-economic equity in health care between different local areas of England. This makes it hard to draw conclusions about how far inequities are changing over time, how well England is performing on equity in health care compared with other countries, and whether some areas of England are succeeding better than others at tackling health care inequities.

Finally, almost all the empirical research focuses on health care received during a particular period rather than over the course of individual lifetimes. This absence of a lifetime perspective means that issues such as poor health leading to low incomes, or low incomes leading to later poor health, are not addressed by studies that focus on whether care currently is allocated according to current need or whether this allocation favours the currently poor or the currently rich.

The remainder of the paper is organised as follows. Section 'Equity studies and the health production approach' outlines the production function approach to health and Section 'Measuring inequities in health care' discusses methods used to measure inequities in health care. Section 'Findings' presents findings from the studies we review and Section 'Discussion' provides a discussion.

II. Equity studies and the health production approach

We begin by outlining how socio-economic inequalities in health care fit into the broader economic approach that treats health care as one of many inputs into the production of individual health. The approach was introduced by Grossman ( 1972) and focuses on adult health, taking income as given. 18 The basic insight was that health care is an input into a production process rather than a final good. Medical treatment itself is often time-consuming and unpleasant, i.e. more like a 'bad' than a 'good'. What an individual values as a final good is health. Health demand consists of two elements. The first is a consumption effect: health yields direct utility, i.e. individuals feel better when they are healthier. The second is an investment effect (and the novel part of the model): that health increases the number of days available to participate in market and non-market activities.

In a simple production function approach, focusing on adult health under conditions of certainty, individuals get utility from a composite consumption good, Z, and their health stock, H, which depreciates over time, t, at a rate δ:

(1)

(2)

where s is a vector of tastes and I is investment in health. The household production function for health is

(3)

and that for consumption goods is

(4)

where M is a vector of market inputs including medical care, TH is time spent on improving health, E is a vector of factors that affect the production function, including education and environment, X is a vector of market-produced goods and TC is time spent on the composite consumption good. 19

While the basic model is not primarily focused on the issue of socio-economic inequalities in health (and ignores any causal link between health and future income), its components make clear that departures from the allocation of current health care according to current need may arise for (at least) two different types of reason.

First, individuals will vary in their taste for health and consumption. Variation in taste means individuals will choose different levels of investment in health (including medical care) depending on their tastes as well as their resource constraints. This is not necessarily inequitable.

Second, health involves many inputs. Other inputs into health production include health-related consumption such as diet, physical activity, smoking, drinking and narcotic use. The ability to produce health from a given set of inputs will depend on the individual's knowledge (education) and the environment they face, including health-related factors such as living and working conditions, stressful aspects of the social and economic environment, air pollution, noise pollution, water pollution, transport safety and violent crime. Thus even if health care prices are set to zero, there are many other factors that may lead to socio-economic inequality in health and in the receipt of health care. First, poorer (more socio-economically disadvantaged) individuals will have fewer resources (wealth, human capital, social capital) to invest in the production of health. Thus a unit of medical care will be less beneficial than for a richer individual who will have more resources to utilise alongside that medical care. Second, the nature of a low-income individual's employment and life may also mean they are heavily time-constrained. If so, this will raise the relative prices of time inputs for them and they may therefore value the opportunity costs from using health care (for example, time away from domestic and work duties, travel costs) more highly than the potential health gains, particularly when considering investments in health such as preventive care. Thus poorer individuals may tend to use less preventive health care when facing no immediate pain or disability, and present to health care providers at a later stage of illness. This will mean that when they finally access health care, they will be in greater need and require more health care inputs. Third, the quality of care received may depend in part upon the intensity and effectiveness of care-seeking behaviour - for example, in navigating through a complex health care system and lobbying providers for the best-quality care. Again, individuals with fewer resources will be less equipped to undertake such activity. All these reasons mean that we would expect, even in a system with zero monetary prices, to see poorer individuals having a greater need for care and requiring more health care relative to that need. To the extent that measures of inequities do not take into account the resources required by the individual to use health care inputs, they will present an overly positive picture of inequities in the receipt of care.

III. Measuring inequities in health care

The empirical literature on social inequality in health care usually adopts a normative perspective that seeks to distinguish 'appropriate' or 'fair' inequalities in health care from 'inappropriate' or 'unfair' inequalities. To mark this distinction, it is common in the literature to use the word 'inequities' (in Europe) or 'disparities' (in the US) to mean 'unfair' social inequalities in health care, though there is considerable variation in usage. 20 The basic idea is to measure departures from 'horizontal equity' - the appropriately equal treatment of people who are alike in relevant respects. Most authors in this literature define horizontal equity in health care in terms of the principle of 'equal access for equal need' - that citizens with equal need for health care should have equal access to high-quality care. 21 Some authors argue that the appropriate objective should be the more demanding one of equal utilisation for equal need. 22 However, other authors argue that it is important to respect individual preferences about how far to seek, accept and adhere to needed health care. 23 In practice, the empirical literature has focused on equality of utilisation, and interpreted this either as the relevant equity objective or as a proxy for equality of access. 24

To measure departures from horizontal equity, the basic research strategy is to measure cross-sectional associations between a socio-economic variable (for example, income) and a health care variable (for example, doctor visits) after adjusting for 'appropriate' or 'fair' differences due to differences in individual needs and, in some cases, preferences. 25 This is methodologically challenging for several reasons.

Ascertaining the appropriate magnitude of adjustment for 'fair' differences requires a potentially contestable normative assumption about how far people with different needs and preferences should be treated differently. 26 This is an assumption about 'vertical equity' - the appropriately different treatment of people who differ in relevant respects. Except in rare cases where it is reasonable to assume that all individuals have identical needs and preferences for health care, it is not possible to measure horizontal equity in health care without making a normative assumption about vertical equity. The simplest and most common vertical equity assumption is that the current population average relationship between need and utilisation is appropriate (i.e. 'on average, the system gets it right'). This assumption implies that need adjustment should be performed by estimating needed health care using population average reference values of non-need characteristics. An alternative assumption is that the need-utilisation relationship among socio-economically advantaged individuals is appropriate (i.e. 'the system gets it right for socio-economically advantaged patients'). Different vertical equity assumptions involving different reference values are also possible, as are assumptions based on expert opinion about what the need-utilisation relationship should ideally be, rather than on data on what it currently is. 27

Another problem is that data on health care needs are often limited and may underestimate the additional needs of socio-economically disadvantaged individuals. 28 Data for the empirical studies of departures from equity in health care tend to be drawn either from household survey data or from administrative data (primarily routine hospital data, but also data on care in primary settings and specialised clinical registry data for particular conditions). One common limitation in both kinds of data is lack of detailed information on either stage of illness or multi-morbidity (the combination of multiple diseases in the same individual), both of which may tend to be more severe in deprived individuals. 29 A particular limitation in survey data is reporting bias in measures of self-reported health, whereby disadvantaged individuals tend to self-report better subjective health despite having worse 'objective' disease status from an external clinical perspective. This applies both to general measures of health and to reports of specific health conditions. 30

Another limitation of general household survey data is that small sample sizes preclude studies of inequalities in the use of specific health care technologies for specific conditions. 31 Although administrative data have larger sample sizes, they have limited measures of ability to pay. For example, UK administrative data on health do not include measures of patient or household ability to pay and have not been matched to other administrative data that provide such measures, such as tax records. The approach taken in all administrative data studies in England is to proxy ability to pay by measures of the socio-economic status of the population of the area in which the patient lives. Most studies in England since 2001 have used variants of the 'Index of Multiple Deprivation' based on just over 32,000 English small-area neighbourhoods of approximately 1,500 people (minimum 1,000 and maximum 3,000) that were introduced in the 2001 Census. Area deprivation is correlated with individual socio-economic status, due to house price differentials and wealth-related housing segregation. However, the correlation is imperfect - rich individuals may live in deprived areas and poor individuals may live in non-deprived areas. Furthermore, there are potential biases due to migration and consequent change in the individual-level composition of areas over time.

Another challenge is heterogeneity in needs and preferences between individuals. This can mean, for example, that the degree of horizontal inequity may vary between groups of individuals. 32, 33 So an overall estimate of horizontal inequity that aggregates across different types of patient without explicitly modelling the interactions between need, preferences and socio-economic status may suffer from a composition effect. Finally, almost all analyses to date take current income and need (however defined) as given and have examined departures from equity at one point in time. If there is pro-rich inequality at all ages, then a cross-sectional snapshot will underestimate the extent to which health care is pro-rich. More broadly, they do not take into account the dynamic relationship between health and ability to pay.

As a result of these methodological challenges, it is often hard to draw clear normative conclusions about 'horizontal inequity' as opposed to positive conclusions about inequality.

IV. Findings

1. General population studies of the whole health care sector

Most economic studies focus on the general population and seek to provide a comprehensive picture of health care inequality across the health care sector as a whole. We review general population studies under three categories: (a) health care quantity (including supply, utilisation and expenditure), (b) health care quality (including process quality and patient experience) and (c) health care outcomes.

a) Health care quantity

Table 1 summarises selected recent national studies of socio-economic inequality in overall health care supply, utilisation and expenditure in England.

NHS inpatient hospital costs (including emergency) [admin data]

2010-11 to 2014-15

None

Substantial pro-poor inequality, e.g. relative gap of 35% between most and least deprived fifths of patients aged 65 and over (£5,605 vs £4,146)

Kelly, Stoye and Vera-Hernández, this issue

One survey study found no significant income-related or education-related inequality in day-case and inpatient hospital utilisation after allowing for need during the short window 1998-2000. 41 However, a study using administrative data at small-area level for 2000-08 found significant 'pro-poor' inequality in both outpatient and non-emergency inpatient hospital care in each year of the period, after allowing for available small-area measures of need such as population size, age-sex structure and disease prevalence from primary care pay-for-performance disease registries. 42

Analysis of health care expenditure in England requires administrative data, since survey respondents are not billed for their NHS care and do not know how much it costs. Two recent studies have examined the socio-economic distribution of hospital expenditure using whole-population hospital administrative data. Both find that hospital expenditure is substantially concentrated on poorer people. Kelly, Stoye and Vera-Hernández (this issue) find a relative gap of 35 per cent between the most and least deprived fifths of patients aged 65 and over (£5,605 versus £4,146). Asaria, Doran and Cookson ( 2016) find a relative gap of 31 per cent between the most and least deprived fifths of all-age population (£597 versus £455).

b) Health care quality

Table 2 summarises recent national studies of socio-economic inequality in both the quality and outcomes of health care.

Primary care process quality [QOF admin data] a

2004-05 to 2011-12

None b

Slight pro-rich inequity (4%) reducing over time

Asaria, Ali et al., 2016

Proportion of people feeling supported to manage their condition [GP Patient Survey]

2012 to 2014

None b

Moderate pro-rich inequity, e.g. most deprived fifth 10 percentage points lower than least deprived fifth

Department of Health, 2015

Patient-rated experience of NHS services [GP Patient Survey]

2012 to 2014

None b

Slight pro-rich inequity, e.g. percentage point gaps between most and least deprived fifths of 4.7 (GP services), 3 (out-of-hours GP services) and 4 (dental services)

Department of Health, 2015

Patient-rated access to NHS services [GP Patient Survey]

2012 to 2014

None b

Slight pro-rich inequity, e.g. percentage point gaps between most and least deprived fifths of 5 (GP services) and 3 (dental services)

Department of Health, 2015

In the UK, in contrast with the US, 43 the study of inequalities in health care quality is relatively recent. Arguably, as quality is measured for patients who are already receiving care, it is less necessary to standardise for need in such studies.

There has been an increase in the availability of measures of quality of care in the UK since the early 2000s. The UK primary care pay-for-performance scheme introduced in 2004-05 includes data on practice-level primary care clinical process quality for a number of different conditions. One study examined an average of these scores and found a gap of 4 per cent between the most deprived and least deprived fifth of practices in 2004-05, which fell to 0.8 per cent in 2006-07. 44 A more recent study updated this analysis to 2011-12 and found ongoing inequality reductions. 45

The UK Department of Health recently reported a series of estimates of the difference in health care patient experience at small-area level, based on data from the annual national GP Patient Survey. 46 Characterising small areas by deprivation, it found pro-rich differences between the top and bottom deprivation quintile groups in the proportion of people feeling supported to manage their condition, in patient-rated experience of GP services and NHS dental services and in patient-rated access to GP and dental services. 47

Finally, a recent study of equity in palliative care used data from the 2013 National Survey of Bereaved People and found substantial pro-rich inequalities in bereaved people's experiences of care for a recently deceased close relative - for example, in the probability of rating the overall quality of care as 'outstanding' or 'excellent', in the probability of receiving as much support as needed from health and social services and in the probability of dying at home. 48

c) Health care outcomes

To date, most studies of socio-economic inequality in overall health care outcomes have been conducted at population level and have adjusted for age and sex but not for morbidity and other risk factors beyond the immediate control of health care providers. One study of administrative data from 2004-05 to 2011-12, for example, found substantial pro-rich inequality in both avoidable emergency hospitalisation and mortality amenable to health care, which reduced slightly during the period. 49 However, we cannot draw conclusions about how far these pro-rich inequalities are 'unfair' inequalities attributable to inadequate health care, as opposed to worse health among poorer populations attributable to wider health production processes.

Patient-level studies of health care outcomes can control more accurately for morbidity and other individual-level risks of poor health care outcomes that are beyond the immediate control of health care providers. A limitation, however, is that patient-level studies focus on patients who have succeeded in getting access to health care and so may give a selective picture of inequalities in the general population - including outcomes for people who do not receive appropriate care. Furthermore, morbidity at the point of treatment may partly be due to inadequate health care in past years. A longitudinal perspective on fairness in health care would therefore need to allow for the dynamic relationship between health care and morbidity and not merely treat current morbidity as an exogenous risk factor.

2. Condition-specific studies of specific sub-populations

In this subsection, we review a selection of recent national studies of inequalities in services for specific clinical conditions. One of the advantages of the condition-specific approach is that there is less heterogeneity in need within conditions than across conditions. However, there is no reason to expect no heterogeneity nor that this heterogeneity is not socially graded.

Re-operation rates [admin data]

2000 to 2008

Age, sex, co-morbidity

More deprived patients more likely to require re-operation following bowel cancer surgery

Burns et al., 2011

Survival rates [admin data]

1974 to 2004

Age, sex

Pro-rich inequality for rectal and breast cancer

Lyratzopoulos et al., 2011

a) Cancer

It is well established that even in England, where the monetary price of care is zero, poorer patients tend to present at a later stage of cancer. For example, using data from 1998 to 2000, one study found that patients in the least deprived fifth of neighbourhoods are more likely to be diagnosed with breast cancer at early stage I (39.2 per cent versus 36.3 per cent) and less likely to be diagnosed at advanced stage IV (5.0 per cent versus 7.0 per cent). 53 Poorer patients are also more likely to be admitted as emergencies. A study using data from 1999 to 2006 found that cancer patients from the most deprived fifth of neighbourhoods in England are more likely to be admitted to hospital as emergencies than those from the least deprived fifth (colorectal cancer 37.9 per cent versus 28.9 per cent, breast cancer 17.0 per cent versus 10.7 per cent and lung cancer 55.2 per cent versus 48.3 per cent). 54 The same study also found that deprived patients are less likely to receive the preferred surgical procedures for these cancers. It is not known how far these patterns reflect differences in care-seeking behaviour and late presentation, as opposed to poorer-quality care for patients of lower socio-economic status (SES).

b) Circulatory disease

In contrast to cancer treatment, several recent studies of circulatory disease have found fewer differences across SES groups. One study using Health Survey for England data from 2003 and 2006 found pro-rich inequalities in outpatient visits, electrocardiography tests and heart surgery. 58 Another study, using practice-level administrative data from 2006-07, found that practices serving more deprived populations were less likely to prescribe statins (a cholesterol-lowering medication) for primary prevention of cardiovascular disease in low-risk patients. 59 However, a patient-level study using follow-up data for 2005-07 from the Whitehall study of civil servants found no socio-economic difference in use of cholesterol-lowering medication related to employment grade. 60 Furthermore, studies looking at secondary prevention following cardiovascular events or diagnosis in higher-risk patients have found no pro-rich inequities. Using patient-level clinical registry data from 1995 to 2005, one study found no deprivation-related difference in secondary prevention after stroke. 61 Another study using patient-level clinical registry data found no deprivation-related inequities in medical treatments for patients following heart attack or with chronic angina or requiring secondary prevention. 62 After controlling for available measures of need, a study using data from 1985 to 1999 found no association between social position and the use of cardiac procedures or secondary prevention drugs. 63 Finally, a small-area study using data from 2001 to 2008 also found no clear evidence of inequality in coronary revascularisation procedures favouring people living in less deprived neighbourhoods. 64, 65

c) Hip and knee joint replacement for osteoarthritis

Finally, a recent study using patient-level administrative data found evidence of deprivation-related inequalities in patient-reported outcome measures after hip and knee replacement surgery from 2009 to 2011. 77 These inequalities were attenuated but not eliminated by adjusting for risk in the form of pre-operative health and disease severity. However, the adjusted differences were small: absolute differences between top and bottom deprivation fifths of 2.8 and 2.4, on a scale of 0 to 48, respectively for hip replacement (Oxford Hip Score) and knee replacement (Oxford Knee Score).

d) Preventive care

Table 4 summarises selected recent national studies of socio-economic inequality in preventive care, including dental check-ups, eye tests and condition-specific studies of adult screening and childhood vaccination.

Bowel cancer follow-up testing after initial screening shows there may be cancer [admin data]

2006 to 2009

Slight pro-rich inequity: least deprived fifth 3.5% more likely to attend follow-up colonoscopy than most deprived fifth (levels of 89.5% and 86.4%)

Morris et al., 2012

Human papilloma virus (HPV) cervical cancer vaccine [admin data]

2008-09 to 2010-11

No pro-rich inequity: deprivation-related differences in 2007-08 pilot disappeared by 2008-09, but ethnicity-related inequities remained

Fisher et al., 2014

Preventive care inequalities are pervasive and can be substantial, as one would expect from a health production perspective in so far as poorer individuals are less able and willing to invest in health. 78 In addition, neither dental check-ups nor eye tests are universally funded by the NHS, though there are various age- and means-related subsidies. 79

Most condition-specific studies of equity in preventive care focus on screening and vaccination programmes that target particular 'at-risk' sub-populations. The measurement of need is relatively straightforward in studies of this kind, in so far as everyone in a particular age-sex group is considered to need the service in question. For example, the national bowel cancer screening programme in England currently recommends and offers colonoscopy and stool examination screening for colon cancer to all men and women between the ages of 60 and 75 years. 80

In general, poorer and less-educated patients are less likely to participate in adult screening programmes. For example, in the early stages of the NHS bowel cancer screening programme from 2006 to 2009, there were substantial differences in uptake between people living in the most and least deprived fifth of neighbourhoods in England of 35 per cent versus 61 per cent. 81 Even following positive screening results, people living in the most deprived fifth of neighbourhoods were still a little less likely to attend appointments for further diagnostics and treatment. 82 Children from poor families are also less likely to participate in childhood vaccination programmes. For example, coverage of the measles, mumps and rubella (MMR) vaccine during the 1990s was lower in the most deprived fifth of neighbourhoods of England than in the least deprived fifth (86 per cent versus 92 per cent in 1992 and 85 per cent versus 87 per cent in 2001). 83 Interestingly, this inequality subsequently reversed in the mid 2000s following adverse press coverage of the MMR vaccination, as parents from more affluent neighbourhoods responded more negatively to this media coverage. Socio-economic inequality was also found in uptake of human papilloma virus (HPV) cervical cancer vaccine during pilots in the financial year 2007-08. 84 This was found to disappear in the subsequent national roll-out, though ethnic inequalities remained from 2008-09 to 2010-11. 85

These findings are mirrored in other high-income countries. A recent study of 13 European countries excluding England found pro-rich and pro-educated inequities in breast and colon cancer screening, blood tests and flu vaccination using data from the Survey of Health, Ageing and Retirement in Europe pooled across three survey waves around 2004, 2007 and 2009. 86 Data from the British Household Panel Survey suggest that participation in courses leading to qualifications increases the probability of having a smear test by between 4.3 and 4.4 percentage points. 87 The WHO World Health Survey of 70 countries in 2002-03 found slight to moderate pro-rich inequity in cervical cancer screening for women aged 25-64 in 50 out of the 67 countries with screening data 88 and pro-educated inequity pooling across all 22 of the participating European countries including the UK. 89 While the latter finding was not statistically significant within the UK alone, the sample was small (521 women). A larger study of 3,185 women aged 40-74 in 2005-07 did find statistically significant educational and ethnic inequities in cervical screening. 90

V. Discussion

Our review suggests the following stylised facts about the socio-economic distribution of health care, after some kind of adjustment for need, in England:

1. Poorer individuals consume a greater quantity of publicly-funded NHS health care in terms of overall expenditure and utilisation.

2. Richer patients tend to achieve better health care outcomes (for example, surgical mortality or preventable hospitalisation) even after adjusting for observable risk factors.

3. Richer individuals tend to present to health care providers at an earlier stage of disease progression; consume more medical specialist visits including privately-funded visits; consume more preventive NHS care such as screening and vaccination services; are more likely to receive a needed NHS hip or knee replacement operation and to be referred by their doctor for specialist investigation of hip pain; have shorter waiting times for heart bypass surgery and angioplasty; may receive slightly better NHS quality of care for some conditions as measured by clinical process quality indicators; and report slightly better patient experiences.

The picture is thus one of an overall pro-poor distribution of quantity but a pro-rich distribution of quality, experience and access to services including waits for treatment. However, in terms of magnitude, the pro-rich inequity gaps are generally slight (5 per cent or less) and it is unusual to find a need- or risk-adjusted gap of greater than 10 per cent between the richest and poorest fifths. Furthermore, studies rarely provide detailed information about how far these pro-rich inequities are attributable to the behaviour of NHS health care providers as opposed to socio-economic differences in health care-seeking and self-care behaviour. We therefore recommend that future studies report marginal effects, as well as or instead of concentration indices and odds ratios, so that readers can calculate absolute differences between social groups allowing for covariates.

These stylised facts make sense in the context of a health production approach where health care is only one input into health and the costs of other inputs differ systematically with income. Individuals who have fewer resources will tend to have worse health at all stages of life. This helps to explain fact (1), since people with worse health need more health care and generally demand more health care in a universal health system such as the English NHS, which sets prices at or close to zero. It also helps to explain fact (2), since people with worse health are at risk of worse health care outcomes. It also helps rationalise the set of facts under point (3). Poorer individuals invest less time and money in improving their health because they have fewer resources to invest, face higher opportunity costs in terms of lost income and household production relative to their limited resources, and may value future health benefits less if they have a higher rate of time preference. 91

Finally, important gaps in knowledge remain. There are few studies that compare change over time, or that compare performance on equity in health care between different sub-national areas to help managers learn lessons about effective ways of reducing health care inequalities. The selection of condition-specific study topics is skewed by political priorities and researcher interest and convenience. A more systematic approach would place greater emphasis on conditions involving high disease burden, high expenditure, and high potential health gains through more vigorous implementation of cost-effective health care. Research is needed to tell us how far inequalities are due to the behaviour of providers and how far to individual choices about health care. 92 Studies of inequalities in health care could usefully be integrated with studies of wider inequalities in health - such as a recent study of trends in inequality in cardiovascular mortality that examines the contributions of trends in treatment uptake and risk factors. 93 Another future research direction is to exploit internationally comparable administrative data sets to make more detailed condition-specific comparisons between health care equity in different countries. 94

Finally, as is clear from this review, most of the research on whether health care is allocated according to need has focused on appropriate adjustment for need, taking resources as given. But to the extent that ill health drives both health and socio-economic factors, particularly employment, earnings and income, it is no surprise that the poor use more health care. A life-cycle perspective, in which attention is given to the relationship between income and need, will allow a fuller assessment of the extent to which this is inequitable.

1. 1

2. 2
Kelly, Stoye and Vera-Hernández, this issue.

3. 16

4. 19
This basic model has been extended to incorporate uncertainty (Dardanoni and Wagstaff, 1990), which is central to certain forms of health care such as screening and diagnosis that are essentially about reducing uncertainty, and to incorporate pre-adulthood stages of life. Current models of health and human capital development during the early years of life emphasise (1) the role of in utero nutrition and physiological development on outcomes in later life and (2) the role of families and childhood environments in shaping skills and character traits that influence both income and health in later life (Fogel, 2003; Heckman, 2012; Galama and van Kippersluis, 2013; Almond, Currie and Meckel, 2014; Heckman and Mosso, 2014).

5. 30
Sen, 2002a; Bago d'Uva et al., 2008; Bago d'Uva, Jones and van Doorslaer, 2009; Johnston, Propper and Shields, 2009; Johnston et al., 2010.

6. 33
For example, there might be substantial horizontal inequity between rich and poor patients with mildly elevated blood pressure (a 'low' level of need) but no horizontal inequity among patients with severe heart disease (a 'high' level of need).

7. 40
Van Doorslaer et al., 2000; van Doorslaer, Koolman and Jones, 2004; van Doorslaer, Masseria and Koolman, 2006; Bago d'Uva, Jones and van Doorslaer, 2009; Devaux and de Looper, 2012; Devaux, 2015.

8. 68

9. 76
The overall growth in inpatient utilisation of heart surgery (coronary artery bypass grafting, CABG) was around 35 per cent whereas the reduction in waiting times for CABG was nearly 70 per cent. Waiting times for CABG fell from around 160 days to around 50 days.

10. 80
Data on individual health could, in principle, provide further useful information about need within such groups. For example, a person aged 60 with particular risk factors such as a family history of colon cancer may be considered to need screening more than another person of the same age without those risk factors.

Ancillary

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DOI

10.1111/j.1475-5890.2016.12109

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© 2016 The Authors. Fiscal Studies published by John Wiley & Sons Ltd. on behalf of Institute for Fiscal Studies

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Keywords

health care;

inequalities;

socio-economic factors;

I14;

I18

Publication History

Issue online:

Version of record online:

Funded by

Economic and Social Research Council. Grant Number: ES/J023108/1

National Institute for Health Research. Grant Number: SRF-2013-06-015

References

Agency for Healthcare Research and Quality (2014), 2014 National Healthcare Quality and Disparities Report, Rockville, MD.

Asaria, M., Ali, S. et al. (2016), 'How a universal health system reduces inequalities: lessons from England', Journal of Epidemiology & Community Health, doi:10.1136/jech-2015-206742.

Asaria, M., Doran, T. and Cookson, R. (2016), 'The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation', Journal of Epidemiology & Community Health, doi: 10.1136/jech-2016-207447.

Department of Health (2000), The NHS Plan: A Plan for Investment, a Plan for Reform.

Department of Health (2012), 'Health and Social Care Act 2012: fact sheets', http://www.dh.gov.uk/health/2012/06/act-explained/.

Department of Health (2015), NHS Outcomes Framework: Indicators for Health Inequalities Assessment.

Devaux, M. and de Looper, M. (2012), 'Income-related inequalities in health service utilisation in 19 OECD countries, 2008-2009', OECD Health Working Paper no. 58, doi:10.1787/5k95xd6stnxt-en.

Dixon, J., King, D., Matosevic, T., Clark, M. and Knapp, M. (2015), Equity in the Provision of Palliative Care in the UK: Review of Evidence, https://www.mariecurie.org.uk/globalassets/media/documents/policy/campaigns/equity-palliative-care-uk-report-full-lse.pdf.

Forde, I., Chandola, T., Raine, R., Marmot, M. G. and Kivimaki, M. (2011), 'Socioeconomic and ethnic differences in use of lipid-lowering drugs after deregulation of simvastatin in the UK: the Whitehall II prospective cohort study', Atherosclerosis, vol. 215, pp. 223-8.

Institute of Medicine (2001), Crossing the Quality Chasm: A New Health System for the 21st Century, Washington DC: National Academy Press.

OECD (2014), OECD Health Data. Available at http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.

Schoen, C. and Osborn, R. (2010), The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries, http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2010/nov/int-survey/pdf_2010_ihp_survey_chartpack_11182010_final_white_bkgd.pdf.

World Health Organisation (2000), The World Health Report 2000: Health Systems - Improving Performance.

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Citing Literature

Original Article

†
Submitted August 2015.

The authors thank Antonio Rojas-Garcia for his help with the literature searching, Josie Dixon, Julian Le Grand and an anonymous referee for helpful comments, and Judith Payne for excellent copy-editing, though the authors take full responsibility for all remaining errors and omissions. Financial support is from an Economic and Social Research Council (ESRC) Professorial Fellowship to Propper (ES/J023108/1) and a National Institute for Health Research (NIHR) Senior Research Fellowship to Cookson (SRF-2013-06-015). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Abstract

This paper reviews what is known about socio-economic inequalities in health care in England, with particular attention to inequalities relative to need that may be considered unfair ('inequities'). We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups 'slight', inequalities of 5-15 per cent 'moderate' and inequalities of more than 15 per cent 'substantial'. Overall public health care expenditure is substantially concentrated on poorer people. At any given age, poorer people are more likely to see their family doctor, have a public outpatient appointment, visit accident and emergency, and stay in hospital for publicly-funded inpatient treatment. After allowing for current self-assessed health and morbidity, there is slight pro-rich inequity in combined public and private medical specialist visits but not in family doctor visits. There are also slight pro-rich inequities in overall indicators of clinical process quality and patient experience from public health care, substantial pro-rich inequalities in bereaved people's experiences of health and social care for recently deceased relatives, and mostly slight but occasionally substantial pro-rich inequities in the use of preventive care (for example, dental check-ups, eye tests, screening and vaccination) and a few specific treatments (for example, hip and knee replacement). Studies of population health care outcomes (for example, avoidable emergency hospitalisation) find substantial pro-rich inequality after adjusting for age and sex only. These findings are all consistent with a broad economic framework that sees health care as just one input into the production of health over the life course, alongside many other socio-economically patterned inputs including environmental factors (for example, living and working conditions), consumption (for example, diet and smoking), self-care (for example, seeking medical information) and informal care (for example, support from family and friends).

Policy points

Poorer and more socially disadvantaged people tend to consume more health care at any given age, in terms of both volume and cost, because they are sicker.

Richer and more socially advantaged people tend to present to health care providers at an earlier stage of illness and to consume more preventive care.

There are slight pro-rich inequities in some clinical process quality and patient experience measures but bigger inequities in some forms of preventive care and care involving substantial elements of co-payment and/or non-medical personal care.

There are substantial pro-rich inequalities in population health care outcomes (for example, potentially avoidable mortality and hospitalisation), but it is not known how far these reflect inadequate care rather than morbidity beyond the control of health and social services.

To address inequalities in health care, policymakers need better information about how local inequalities change over time in response to local policy changes, together with longitudinal analysis of health care inequalities over the life course.

I. Introduction

This paper reviews evidence on socio-economic inequalities in health care in England, a country that consistently comes near the top of international league tables of equity in health care financing. 1 Benefit incidence studies show that public health care expenditure in England disproportionately benefits poorer people. 2 However, this does not necessarily mean that health care is distributed fairly in relation to need, since poorer people tend to be sicker and so have greater need for health care. So our review pays close attention to empirical studies that have attempted to allow for need in order to assess how far socio-economic differences in health care may be considered unfair or inequitable.

England's tax-funded National Health Service (NHS) provides a relatively generous package of health care, free at the point of use, which makes up nearly 85 per cent of national health care expenditure. Whilst the level of public funding is high, however, England is not an outlier. All high-income countries offer their citizens a substantial package of publicly-funded health care, including countries with relatively low shares of public expenditure on health such as the US and Chile, which spend just under 50 per cent compared with the OECD average of 73 per cent in 2012. 3 While all health care systems in wealthy countries have equity goals relating to access to, and/or delivery of, health care as well as its financing, 4 the English NHS is unusual in also having explicit policy objectives relating to reducing inequalities in health care outcomes. These objectives were first articulated in 2000 5 and formalised in the 2012 Health and Social Care Act. 6

Associated with these policy goals is a large literature on the distribution of health care and of health in the UK and England. In this review, we confine our attention primarily to the literature on inequalities that takes an economics perspective. Under this umbrella, we focus mainly on health care and present studies of departures from equality in health care supply, utilisation, expenditure and quality. We also devote some space to recent literature on inequality in patient experience and outcomes. We do not review evidence of inequality in health care financing since the NHS is largely funded through general taxation and few people in England report financial difficulties in paying health care bills or face catastrophic medical expenditures. 7

We focus on variations in health care associated with socio-economic characteristics related to ability to pay, such as income, education, deprivation and social class, although there is also evidence of social inequality by other individual characteristics such as ethnicity, 8 geographical location, 9 age, 10 gender, 11 veteran status, 12 type of illness 13 and other aspects of disadvantage or vulnerability. 14 As shorthand, we use the term 'poor' in a broad sense to mean 'socio-economically disadvantaged'.

We update previous reviews of studies of health care inequalities in England published in the 1990s and early 2000s 15 by identifying major national studies conducted subsequently. We also draw on major cross-country studies and reviews of evidence in the US. 16 However, our aim is to identify stylised facts about health care inequalities rather than to conduct a systematic review of this large, diverse and multidisciplinary empirical literature.

We start by reviewing general population studies that aim to provide a comprehensive picture of inequality in the health care sector as a whole, across a broad range of different clinical conditions. We then include a selection of recent national studies of inequalities in services for specific clinical conditions, which are reasonably representative of the literature. We focus on three common and high-profile conditions: cancer, circulatory disease and osteoarthritis. Cancer and circulatory disease are policy priorities due to their high mortality rates and cost, and osteoarthritis is a policy priority due to long hospital waiting times for hip and knee joint replacement. We also present selected studies of preventive services such as screening for cervical cancer, which are particularly prone to pro-rich inequality for reasons to do with health production that are explained in Section 'Equity studies and the health production approach'. We do not review studies of inequality in long-term care, such as home care and residential nursing home services for the elderly. In England, public funding for long-term care is means tested and services are organised separately from the NHS as part of local government social care services.

Almost all the evidence we cite focuses on publicly-funded NHS health care, since data on privately-funded health care are generally not available from routine administrative data and only sometimes included in survey data. This is a limitation, since privately-funded care makes up a substantial proportion of elective hospital care for low-risk procedures and some forms of preventive care such as diagnostic tests and dentistry. Furthermore, important non-medical forms of prevention are privately funded - for example, housing quality, food quality and gym memberships.

Wherever possible, we seek to cite simple measures of relative inequality that are easy to compare across studies of different kinds of health care, such as relative gaps between the most and least socio-economically disadvantaged quintile groups of people in England. We call inequalities of 5 per cent or less between the most and least deprived socio-economic quintile groups 'slight', inequalities of 5-15 per cent 'moderate' and inequalities of more than 15 per cent 'substantial'. These criteria are arbitrary, but at least they are explicit and help us to achieve a degree of consistency in our conclusions about the size of different inequalities. Even this simple classification is not always possible, however, since there is substantial reporting diversity in the literature. For example, much of the health economics literature only reports concentration indices, which are hard to interpret, and much of the health services research literature only reports odds ratios from logistic regression, which - unlike rate ratios and relative risks - can be misleading without knowledge of baseline risks. 17 To facilitate comparison of the magnitude of inequality between different studies, we therefore recommend that future studies report marginal effects, as well as or instead of concentration indices and odds ratios, so that readers can calculate absolute differences between social groups allowing for covariates. There is also reporting diversity due to different units of analysis (for example, individual, household, small area, large area), different data sources (for example, whole-population administrative data versus sample survey data) and different methods of adjusting for need (for example, direct versus indirect standardisation and different sets of need variables). Another key limitation is that the vast majority of studies continue to be snapshots of a particular population at a particular point in time rather than comparative studies. Few studies compare health care equity in England at different points in time, few compare England with other countries and, so far, none has performed detailed comparisons of socio-economic equity in health care between different local areas of England. This makes it hard to draw conclusions about how far inequities are changing over time, how well England is performing on equity in health care compared with other countries, and whether some areas of England are succeeding better than others at tackling health care inequities.

Finally, almost all the empirical research focuses on health care received during a particular period rather than over the course of individual lifetimes. This absence of a lifetime perspective means that issues such as poor health leading to low incomes, or low incomes leading to later poor health, are not addressed by studies that focus on whether care currently is allocated according to current need or whether this allocation favours the currently poor or the currently rich.

The remainder of the paper is organised as follows. Section 'Equity studies and the health production approach' outlines the production function approach to health and Section 'Measuring inequities in health care' discusses methods used to measure inequities in health care. Section 'Findings' presents findings from the studies we review and Section 'Discussion' provides a discussion.

II. Equity studies and the health production approach

We begin by outlining how socio-economic inequalities in health care fit into the broader economic approach that treats health care as one of many inputs into the production of individual health. The approach was introduced by Grossman ( 1972) and focuses on adult health, taking income as given. 18 The basic insight was that health care is an input into a production process rather than a final good. Medical treatment itself is often time-consuming and unpleasant, i.e. more like a 'bad' than a 'good'. What an individual values as a final good is health. Health demand consists of two elements. The first is a consumption effect: health yields direct utility, i.e. individuals feel better when they are healthier. The second is an investment effect (and the novel part of the model): that health increases the number of days available to participate in market and non-market activities.

In a simple production function approach, focusing on adult health under conditions of certainty, individuals get utility from a composite consumption good, Z, and their health stock, H, which depreciates over time, t, at a rate δ:

(1)

(2)

where s is a vector of tastes and I is investment in health. The household production function for health is

(3)

and that for consumption goods is

(4)

where M is a vector of market inputs including medical care, TH is time spent on improving health, E is a vector of factors that affect the production function, including education and environment, X is a vector of market-produced goods and TC is time spent on the composite consumption good. 19

While the basic model is not primarily focused on the issue of socio-economic inequalities in health (and ignores any causal link between health and future income), its components make clear that departures from the allocation of current health care according to current need may arise for (at least) two different types of reason.

First, individuals will vary in their taste for health and consumption. Variation in taste means individuals will choose different levels of investment in health (including medical care) depending on their tastes as well as their resource constraints. This is not necessarily inequitable.

Second, health involves many inputs. Other inputs into health production include health-related consumption such as diet, physical activity, smoking, drinking and narcotic use. The ability to produce health from a given set of inputs will depend on the individual's knowledge (education) and the environment they face, including health-related factors such as living and working conditions, stressful aspects of the social and economic environment, air pollution, noise pollution, water pollution, transport safety and violent crime. Thus even if health care prices are set to zero, there are many other factors that may lead to socio-economic inequality in health and in the receipt of health care. First, poorer (more socio-economically disadvantaged) individuals will have fewer resources (wealth, human capital, social capital) to invest in the production of health. Thus a unit of medical care will be less beneficial than for a richer individual who will have more resources to utilise alongside that medical care. Second, the nature of a low-income individual's employment and life may also mean they are heavily time-constrained. If so, this will raise the relative prices of time inputs for them and they may therefore value the opportunity costs from using health care (for example, time away from domestic and work duties, travel costs) more highly than the potential health gains, particularly when considering investments in health such as preventive care. Thus poorer individuals may tend to use less preventive health care when facing no immediate pain or disability, and present to health care providers at a later stage of illness. This will mean that when they finally access health care, they will be in greater need and require more health care inputs. Third, the quality of care received may depend in part upon the intensity and effectiveness of care-seeking behaviour - for example, in navigating through a complex health care system and lobbying providers for the best-quality care. Again, individuals with fewer resources will be less equipped to undertake such activity. All these reasons mean that we would expect, even in a system with zero monetary prices, to see poorer individuals having a greater need for care and requiring more health care relative to that need. To the extent that measures of inequities do not take into account the resources required by the individual to use health care inputs, they will present an overly positive picture of inequities in the receipt of care.

III. Measuring inequities in health care

The empirical literature on social inequality in health care usually adopts a normative perspective that seeks to distinguish 'appropriate' or 'fair' inequalities in health care from 'inappropriate' or 'unfair' inequalities. To mark this distinction, it is common in the literature to use the word 'inequities' (in Europe) or 'disparities' (in the US) to mean 'unfair' social inequalities in health care, though there is considerable variation in usage. 20 The basic idea is to measure departures from 'horizontal equity' - the appropriately equal treatment of people who are alike in relevant respects. Most authors in this literature define horizontal equity in health care in terms of the principle of 'equal access for equal need' - that citizens with equal need for health care should have equal access to high-quality care. 21 Some authors argue that the appropriate objective should be the more demanding one of equal utilisation for equal need. 22 However, other authors argue that it is important to respect individual preferences about how far to seek, accept and adhere to needed health care. 23 In practice, the empirical literature has focused on equality of utilisation, and interpreted this either as the relevant equity objective or as a proxy for equality of access. 24

To measure departures from horizontal equity, the basic research strategy is to measure cross-sectional associations between a socio-economic variable (for example, income) and a health care variable (for example, doctor visits) after adjusting for 'appropriate' or 'fair' differences due to differences in individual needs and, in some cases, preferences. 25 This is methodologically challenging for several reasons.

Ascertaining the appropriate magnitude of adjustment for 'fair' differences requires a potentially contestable normative assumption about how far people with different needs and preferences should be treated differently. 26 This is an assumption about 'vertical equity' - the appropriately different treatment of people who differ in relevant respects. Except in rare cases where it is reasonable to assume that all individuals have identical needs and preferences for health care, it is not possible to measure horizontal equity in health care without making a normative assumption about vertical equity. The simplest and most common vertical equity assumption is that the current population average relationship between need and utilisation is appropriate (i.e. 'on average, the system gets it right'). This assumption implies that need adjustment should be performed by estimating needed health care using population average reference values of non-need characteristics. An alternative assumption is that the need-utilisation relationship among socio-economically advantaged individuals is appropriate (i.e. 'the system gets it right for socio-economically advantaged patients'). Different vertical equity assumptions involving different reference values are also possible, as are assumptions based on expert opinion about what the need-utilisation relationship should ideally be, rather than on data on what it currently is. 27

Another problem is that data on health care needs are often limited and may underestimate the additional needs of socio-economically disadvantaged individuals. 28 Data for the empirical studies of departures from equity in health care tend to be drawn either from household survey data or from administrative data (primarily routine hospital data, but also data on care in primary settings and specialised clinical registry data for particular conditions). One common limitation in both kinds of data is lack of detailed information on either stage of illness or multi-morbidity (the combination of multiple diseases in the same individual), both of which may tend to be more severe in deprived individuals. 29 A particular limitation in survey data is reporting bias in measures of self-reported health, whereby disadvantaged individuals tend to self-report better subjective health despite having worse 'objective' disease status from an external clinical perspective. This applies both to general measures of health and to reports of specific health conditions. 30

Another limitation of general household survey data is that small sample sizes preclude studies of inequalities in the use of specific health care technologies for specific conditions. 31 Although administrative data have larger sample sizes, they have limited measures of ability to pay. For example, UK administrative data on health do not include measures of patient or household ability to pay and have not been matched to other administrative data that provide such measures, such as tax records. The approach taken in all administrative data studies in England is to proxy ability to pay by measures of the socio-economic status of the population of the area in which the patient lives. Most studies in England since 2001 have used variants of the 'Index of Multiple Deprivation' based on just over 32,000 English small-area neighbourhoods of approximately 1,500 people (minimum 1,000 and maximum 3,000) that were introduced in the 2001 Census. Area deprivation is correlated with individual socio-economic status, due to house price differentials and wealth-related housing segregation. However, the correlation is imperfect - rich individuals may live in deprived areas and poor individuals may live in non-deprived areas. Furthermore, there are potential biases due to migration and consequent change in the individual-level composition of areas over time.

Another challenge is heterogeneity in needs and preferences between individuals. This can mean, for example, that the degree of horizontal inequity may vary between groups of individuals. 32, 33 So an overall estimate of horizontal inequity that aggregates across different types of patient without explicitly modelling the interactions between need, preferences and socio-economic status may suffer from a composition effect. Finally, almost all analyses to date take current income and need (however defined) as given and have examined departures from equity at one point in time. If there is pro-rich inequality at all ages, then a cross-sectional snapshot will underestimate the extent to which health care is pro-rich. More broadly, they do not take into account the dynamic relationship between health and ability to pay.

As a result of these methodological challenges, it is often hard to draw clear normative conclusions about 'horizontal inequity' as opposed to positive conclusions about inequality.

IV. Findings

1. General population studies of the whole health care sector

Most economic studies focus on the general population and seek to provide a comprehensive picture of health care inequality across the health care sector as a whole. We review general population studies under three categories: (a) health care quantity (including supply, utilisation and expenditure), (b) health care quality (including process quality and patient experience) and (c) health care outcomes.

a) Health care quantity

Table 1 summarises selected recent national studies of socio-economic inequality in overall health care supply, utilisation and expenditure in England.

NHS inpatient hospital costs (including emergency) [admin data]

2010-11 to 2014-15

None

Substantial pro-poor inequality, e.g. relative gap of 35% between most and least deprived fifths of patients aged 65 and over (£5,605 vs £4,146)

Kelly, Stoye and Vera-Hernández, this issue

One survey study found no significant income-related or education-related inequality in day-case and inpatient hospital utilisation after allowing for need during the short window 1998-2000. 41 However, a study using administrative data at small-area level for 2000-08 found significant 'pro-poor' inequality in both outpatient and non-emergency inpatient hospital care in each year of the period, after allowing for available small-area measures of need such as population size, age-sex structure and disease prevalence from primary care pay-for-performance disease registries. 42

Analysis of health care expenditure in England requires administrative data, since survey respondents are not billed for their NHS care and do not know how much it costs. Two recent studies have examined the socio-economic distribution of hospital expenditure using whole-population hospital administrative data. Both find that hospital expenditure is substantially concentrated on poorer people. Kelly, Stoye and Vera-Hernández (this issue) find a relative gap of 35 per cent between the most and least deprived fifths of patients aged 65 and over (£5,605 versus £4,146). Asaria, Doran and Cookson ( 2016) find a relative gap of 31 per cent between the most and least deprived fifths of all-age population (£597 versus £455).

b) Health care quality

Table 2 summarises recent national studies of socio-economic inequality in both the quality and outcomes of health care.

Primary care process quality [QOF admin data] a

2004-05 to 2011-12

None b

Slight pro-rich inequity (4%) reducing over time

Asaria, Ali et al., 2016

Proportion of people feeling supported to manage their condition [GP Patient Survey]

2012 to 2014

None b

Moderate pro-rich inequity, e.g. most deprived fifth 10 percentage points lower than least deprived fifth

Department of Health, 2015

Patient-rated experience of NHS services [GP Patient Survey]

2012 to 2014

None b

Slight pro-rich inequity, e.g. percentage point gaps between most and least deprived fifths of 4.7 (GP services), 3 (out-of-hours GP services) and 4 (dental services)

Department of Health, 2015

Patient-rated access to NHS services [GP Patient Survey]

2012 to 2014

None b

Slight pro-rich inequity, e.g. percentage point gaps between most and least deprived fifths of 5 (GP services) and 3 (dental services)

Department of Health, 2015

In the UK, in contrast with the US, 43 the study of inequalities in health care quality is relatively recent. Arguably, as quality is measured for patients who are already receiving care, it is less necessary to standardise for need in such studies.

There has been an increase in the availability of measures of quality of care in the UK since the early 2000s. The UK primary care pay-for-performance scheme introduced in 2004-05 includes data on practice-level primary care clinical process quality for a number of different conditions. One study examined an average of these scores and found a gap of 4 per cent between the most deprived and least deprived fifth of practices in 2004-05, which fell to 0.8 per cent in 2006-07. 44 A more recent study updated this analysis to 2011-12 and found ongoing inequality reductions. 45

The UK Department of Health recently reported a series of estimates of the difference in health care patient experience at small-area level, based on data from the annual national GP Patient Survey. 46 Characterising small areas by deprivation, it found pro-rich differences between the top and bottom deprivation quintile groups in the proportion of people feeling supported to manage their condition, in patient-rated experience of GP services and NHS dental services and in patient-rated access to GP and dental services. 47

Finally, a recent study of equity in palliative care used data from the 2013 National Survey of Bereaved People and found substantial pro-rich inequalities in bereaved people's experiences of care for a recently deceased close relative - for example, in the probability of rating the overall quality of care as 'outstanding' or 'excellent', in the probability of receiving as much support as needed from health and social services and in the probability of dying at home. 48

c) Health care outcomes

To date, most studies of socio-economic inequality in overall health care outcomes have been conducted at population level and have adjusted for age and sex but not for morbidity and other risk factors beyond the immediate control of health care providers. One study of administrative data from 2004-05 to 2011-12, for example, found substantial pro-rich inequality in both avoidable emergency hospitalisation and mortality amenable to health care, which reduced slightly during the period. 49 However, we cannot draw conclusions about how far these pro-rich inequalities are 'unfair' inequalities attributable to inadequate health care, as opposed to worse health among poorer populations attributable to wider health production processes.

Patient-level studies of health care outcomes can control more accurately for morbidity and other individual-level risks of poor health care outcomes that are beyond the immediate control of health care providers. A limitation, however, is that patient-level studies focus on patients who have succeeded in getting access to health care and so may give a selective picture of inequalities in the general population - including outcomes for people who do not receive appropriate care. Furthermore, morbidity at the point of treatment may partly be due to inadequate health care in past years. A longitudinal perspective on fairness in health care would therefore need to allow for the dynamic relationship between health care and morbidity and not merely treat current morbidity as an exogenous risk factor.

2. Condition-specific studies of specific sub-populations

In this subsection, we review a selection of recent national studies of inequalities in services for specific clinical conditions. One of the advantages of the condition-specific approach is that there is less heterogeneity in need within conditions than across conditions. However, there is no reason to expect no heterogeneity nor that this heterogeneity is not socially graded.

Table 3 summarises selected national studies of socio-economic inequality in care for cancer, circulatory disease and osteoarthritis. Our selection is reasonably representative of the selection of topics in the published literature, which tends to reflect the priorities of policymakers and researchers rather than a more systematic assessment of importance in terms of expenditure, disease burden or potential health gain. The five disorders with the highest burden of disease in the UK in 2010 were low back pain, falls, major depressive disorder, neck pain and other musculoskeletal disorders. 50 These five disorders receive substantially less attention in the health care inequality literature than cancer (no form of which is in the top 26 disorders by burden of disease), circulatory disease (ischaemic heart disease is number 19 and stroke number 23) and osteoarthritis (number 11). 51 As with the general population studies, most of the condition-specific studies are cross-sectional in nature and do not report trends in health care inequities over time. 52

Cancers

Re-operation rates [admin data]

2000 to 2008

Age, sex, co-morbidity

More deprived patients more likely to require re-operation following bowel cancer surgery

Burns et al., 2011

Survival rates [admin data]

1974 to 2004

Age, sex

Pro-rich inequality for rectal and breast cancer

Lyratzopoulos et al., 2011

Circulatory diseases

Osteoarthritis

a) Cancer

It is well established that even in England, where the monetary price of care is zero, poorer patients tend to present at a later stage of cancer. For example, using data from 1998 to 2000, one study found that patients in the least deprived fifth of neighbourhoods are more likely to be diagnosed with breast cancer at early stage I (39.2 per cent versus 36.3 per cent) and less likely to be diagnosed at advanced stage IV (5.0 per cent versus 7.0 per cent). 53 Poorer patients are also more likely to be admitted as emergencies. A study using data from 1999 to 2006 found that cancer patients from the most deprived fifth of neighbourhoods in England are more likely to be admitted to hospital as emergencies than those from the least deprived fifth (colorectal cancer 37.9 per cent versus 28.9 per cent, breast cancer 17.0 per cent versus 10.7 per cent and lung cancer 55.2 per cent versus 48.3 per cent). 54 The same study also found that deprived patients are less likely to receive the preferred surgical procedures for these cancers. It is not known how far these patterns reflect differences in care-seeking behaviour and late presentation, as opposed to poorer-quality care for patients of lower socio-economic status (SES).

b) Circulatory disease

In contrast to cancer treatment, several recent studies of circulatory disease have found fewer differences across SES groups. One study using Health Survey for England data from 2003 and 2006 found pro-rich inequalities in outpatient visits, electrocardiography tests and heart surgery. 58 Another study, using practice-level administrative data from 2006-07, found that practices serving more deprived populations were less likely to prescribe statins (a cholesterol-lowering medication) for primary prevention of cardiovascular disease in low-risk patients. 59 However, a patient-level study using follow-up data for 2005-07 from the Whitehall study of civil servants found no socio-economic difference in use of cholesterol-lowering medication related to employment grade. 60 Furthermore, studies looking at secondary prevention following cardiovascular events or diagnosis in higher-risk patients have found no pro-rich inequities. Using patient-level clinical registry data from 1995 to 2005, one study found no deprivation-related difference in secondary prevention after stroke. 61 Another study using patient-level clinical registry data found no deprivation-related inequities in medical treatments for patients following heart attack or with chronic angina or requiring secondary prevention. 62 After controlling for available measures of need, a study using data from 1985 to 1999 found no association between social position and the use of cardiac procedures or secondary prevention drugs. 63 Finally, a small-area study using data from 2001 to 2008 also found no clear evidence of inequality in coronary revascularisation procedures favouring people living in less deprived neighbourhoods. 64, 65

c) Hip and knee joint replacement for osteoarthritis

Finally, a recent study using patient-level administrative data found evidence of deprivation-related inequalities in patient-reported outcome measures after hip and knee replacement surgery from 2009 to 2011. 77 These inequalities were attenuated but not eliminated by adjusting for risk in the form of pre-operative health and disease severity. However, the adjusted differences were small: absolute differences between top and bottom deprivation fifths of 2.8 and 2.4, on a scale of 0 to 48, respectively for hip replacement (Oxford Hip Score) and knee replacement (Oxford Knee Score).

d) Preventive care

Table 4 summarises selected recent national studies of socio-economic inequality in preventive care, including dental check-ups, eye tests and condition-specific studies of adult screening and childhood vaccination.

Bowel cancer follow-up testing after initial screening shows there may be cancer [admin data]

2006 to 2009

Slight pro-rich inequity: least deprived fifth 3.5% more likely to attend follow-up colonoscopy than most deprived fifth (levels of 89.5% and 86.4%)

Morris et al., 2012

Human papilloma virus (HPV) cervical cancer vaccine [admin data]

2008-09 to 2010-11

No pro-rich inequity: deprivation-related differences in 2007-08 pilot disappeared by 2008-09, but ethnicity-related inequities remained

Fisher et al., 2014

Preventive care inequalities are pervasive and can be substantial, as one would expect from a health production perspective in so far as poorer individuals are less able and willing to invest in health. 78 In addition, neither dental check-ups nor eye tests are universally funded by the NHS, though there are various age- and means-related subsidies. 79

Most condition-specific studies of equity in preventive care focus on screening and vaccination programmes that target particular 'at-risk' sub-populations. The measurement of need is relatively straightforward in studies of this kind, in so far as everyone in a particular age-sex group is considered to need the service in question. For example, the national bowel cancer screening programme in England currently recommends and offers colonoscopy and stool examination screening for colon cancer to all men and women between the ages of 60 and 75 years. 80

V. Discussion

Our review suggests the following stylised facts about the socio-economic distribution of health care, after some kind of adjustment for need, in England:

1. Poorer individuals consume a greater quantity of publicly-funded NHS health care in terms of overall expenditure and utilisation.

2. Richer patients tend to achieve better health care outcomes (for example, surgical mortality or preventable hospitalisation) even after adjusting for observable risk factors.

3. Richer individuals tend to present to health care providers at an earlier stage of disease progression; consume more medical specialist visits including privately-funded visits; consume more preventive NHS care such as screening and vaccination services; are more likely to receive a needed NHS hip or knee replacement operation and to be referred by their doctor for specialist investigation of hip pain; have shorter waiting times for heart bypass surgery and angioplasty; may receive slightly better NHS quality of care for some conditions as measured by clinical process quality indicators; and report slightly better patient experiences.

The picture is thus one of an overall pro-poor distribution of quantity but a pro-rich distribution of quality, experience and access to services including waits for treatment. However, in terms of magnitude, the pro-rich inequity gaps are generally slight (5 per cent or less) and it is unusual to find a need- or risk-adjusted gap of greater than 10 per cent between the richest and poorest fifths. Furthermore, studies rarely provide detailed information about how far these pro-rich inequities are attributable to the behaviour of NHS health care providers as opposed to socio-economic differences in health care-seeking and self-care behaviour. We therefore recommend that future studies report marginal effects, as well as or instead of concentration indices and odds ratios, so that readers can calculate absolute differences between social groups allowing for covariates.

These stylised facts make sense in the context of a health production approach where health care is only one input into health and the costs of other inputs differ systematically with income. Individuals who have fewer resources will tend to have worse health at all stages of life. This helps to explain fact (1), since people with worse health need more health care and generally demand more health care in a universal health system such as the English NHS, which sets prices at or close to zero. It also helps to explain fact (2), since people with worse health are at risk of worse health care outcomes. It also helps rationalise the set of facts under point (3). Poorer individuals invest less time and money in improving their health because they have fewer resources to invest, face higher opportunity costs in terms of lost income and household production relative to their limited resources, and may value future health benefits less if they have a higher rate of time preference. 91

Finally, important gaps in knowledge remain. There are few studies that compare change over time, or that compare performance on equity in health care between different sub-national areas to help managers learn lessons about effective ways of reducing health care inequalities. The selection of condition-specific study topics is skewed by political priorities and researcher interest and convenience. A more systematic approach would place greater emphasis on conditions involving high disease burden, high expenditure, and high potential health gains through more vigorous implementation of cost-effective health care. Research is needed to tell us how far inequalities are due to the behaviour of providers and how far to individual choices about health care. 92 Studies of inequalities in health care could usefully be integrated with studies of wider inequalities in health - such as a recent study of trends in inequality in cardiovascular mortality that examines the contributions of trends in treatment uptake and risk factors. 93 Another future research direction is to exploit internationally comparable administrative data sets to make more detailed condition-specific comparisons between health care equity in different countries. 94

Finally, as is clear from this review, most of the research on whether health care is allocated according to need has focused on appropriate adjustment for need, taking resources as given. But to the extent that ill health drives both health and socio-economic factors, particularly employment, earnings and income, it is no surprise that the poor use more health care. A life-cycle perspective, in which attention is given to the relationship between income and need, will allow a fuller assessment of the extent to which this is inequitable.

1. 1

2. 2
Kelly, Stoye and Vera-Hernández, this issue.

3. 16

4. 19
This basic model has been extended to incorporate uncertainty (Dardanoni and Wagstaff, 1990), which is central to certain forms of health care such as screening and diagnosis that are essentially about reducing uncertainty, and to incorporate pre-adulthood stages of life. Current models of health and human capital development during the early years of life emphasise (1) the role of in utero nutrition and physiological development on outcomes in later life and (2) the role of families and childhood environments in shaping skills and character traits that influence both income and health in later life (Fogel, 2003; Heckman, 2012; Galama and van Kippersluis, 2013; Almond, Currie and Meckel, 2014; Heckman and Mosso, 2014).

5. 30

6. 33
For example, there might be substantial horizontal inequity between rich and poor patients with mildly elevated blood pressure (a 'low' level of need) but no horizontal inequity among patients with severe heart disease (a 'high' level of need).

7. 40
Van Doorslaer et al., 2000; van Doorslaer, Koolman and Jones, 2004; van Doorslaer, Masseria and Koolman, 2006; Bago d'Uva, Jones and van Doorslaer, 2009; Devaux and de Looper, 2012; Devaux, 2015.

8. 68

9. 76
The overall growth in inpatient utilisation of heart surgery (coronary artery bypass grafting, CABG) was around 35 per cent whereas the reduction in waiting times for CABG was nearly 70 per cent. Waiting times for CABG fell from around 160 days to around 50 days.

10. 80
Data on individual health could, in principle, provide further useful information about need within such groups. For example, a person aged 60 with particular risk factors such as a family history of colon cancer may be considered to need screening more than another person of the same age without those risk factors.

Ancillary

Article Information

DOI

10.1111/j.1475-5890.2016.12109

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© 2016 The Authors. Fiscal Studies published by John Wiley & Sons Ltd. on behalf of Institute for Fiscal Studies

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Keywords

health care;

inequalities;

socio-economic factors;

I14;

I18

Publication History

Issue online:

Version of record online:

Funded by

Economic and Social Research Council. Grant Number: ES/J023108/1

National Institute for Health Research. Grant Number: SRF-2013-06-015

References

Agency for Healthcare Research and Quality (2014), 2014 National Healthcare Quality and Disparities Report, Rockville, MD.

Asaria, M., Ali, S. et al. (2016), 'How a universal health system reduces inequalities: lessons from England', Journal of Epidemiology & Community Health, doi:10.1136/jech-2015-206742.

Asaria, M., Doran, T. and Cookson, R. (2016), 'The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation', Journal of Epidemiology & Community Health, doi: 10.1136/jech-2016-207447.

Department of Health (2000), The NHS Plan: A Plan for Investment, a Plan for Reform.

Department of Health (2012), 'Health and Social Care Act 2012: fact sheets', http://www.dh.gov.uk/health/2012/06/act-explained/.

Department of Health (2015), NHS Outcomes Framework: Indicators for Health Inequalities Assessment.

Devaux, M. and de Looper, M. (2012), 'Income-related inequalities in health service utilisation in 19 OECD countries, 2008-2009', OECD Health Working Paper no. 58, doi:10.1787/5k95xd6stnxt-en.

Dixon, J., King, D., Matosevic, T., Clark, M. and Knapp, M. (2015), Equity in the Provision of Palliative Care in the UK: Review of Evidence, https://www.mariecurie.org.uk/globalassets/media/documents/policy/campaigns/equity-palliative-care-uk-report-full-lse.pdf.

Forde, I., Chandola, T., Raine, R., Marmot, M. G. and Kivimaki, M. (2011), 'Socioeconomic and ethnic differences in use of lipid-lowering drugs after deregulation of simvastatin in the UK: the Whitehall II prospective cohort study', Atherosclerosis, vol. 215, pp. 223-8.

Institute of Medicine (2001), Crossing the Quality Chasm: A New Health System for the 21st Century, Washington DC: National Academy Press.

Johnston, D. W., Propper, C., Pudney, S. E. and Shields, M. A. (2010), 'Is there an income gradient in child health? It depends whom you ask', IZA Discussion Paper no. 4830.

Moscelli, G., Siciliani, L., Gutacker, N. and Cookson, R. (2015), 'Socioeconomic inequality of access to healthcare: does patients' choice explain the gradient?', University of York, Centre for Health Economics (CHE), Research Paper no. 112.

OECD (2014), OECD Health Data. Available at http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.

Schoen, C. and Osborn, R. (2010), The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries, http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2010/nov/int-survey/pdf_2010_ihp_survey_chartpack_11182010_final_white_bkgd.pdf.

Shadmi, E. (2013), 'Multimorbidity and equity in health', International Journal for Equity in Health, vol. 12, p. 59.

World Health Organisation (2000), The World Health Report 2000: Health Systems - Improving Performance.

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Neil Kinnock was on the radio at the weekend, talking about his hero Aneurin Bevan with the journalist Matthew Parris and one of Bevan's biographers, John Campbell. Any conversation about Bevan's life is mostly about the NHS and so it was this time, too. But it was a useful reminder of how, among all the battles fought over its creation, among the fiercest was the question of replacing a patchwork of local provision with a single centralised structure that tried to guarantee that everyone got the same level of care wherever they lived. At that the point the radical, big-government approach petered out. Social care was left where it always had been, with local councils.

Now the Institute for Fiscal Studies (IFS) has published a study looking at the difference in social care provision across England that raises the question of whether it too should be centrally funded. After all, whether it's soaring demand for A&E or delayed discharge from hospital, the impact of inadequate or ill-designed social care services on the overall state of the health service has become the stuff of daily headlines.

Then there is the ageing population. Although we are all healthier in old age, the need for care doesn't track changing demography exactly: men's life expectancy is growing faster than women's, so there are more old couples looking after each other rather than relying on formal care.

George Osborne's response to the incipient social crisis was to set in motion plans to shift the entire cost of locally incurred spending to local taxes, with a system of equalisation that has yet to be explained. He introduced a social care precept allowing an increase of up to 2% in council tax to be spent on social care.

Since the amount councils can raise through council tax depends on their tax base, these changes are - as the IFS points out - hitting poorer councils much harder than well-off ones, even though in theory, the introduction of national criteria for eligibility for paid-for social care should mean a reasonably equitable approach. The IFS study found that cuts in social care were much steeper in metropolitan areas such as Greater Manchester, Tyneside and Greater Birmingham, which typically have significantly higher levels of need, than in the south of England (although that may be partly because there are more older people in the south).

But the distinction between what we pay for and what we expect wider society to support is more than just a matter of an arbitrary geographical divide. We are so familiar with it that we rarely ponder the palpable inequity between providing free care for, say, a cancer patient, regardless of their wealth, while charging someone with dementia who also has some modest assets.

Councils argue that keeping older people well is about much more than care homes and clearing hospital beds

Because social care is provided locally, the national focus is always on the NHS. So although last month's budget made another £2bn available for social care, it is being delivered in a way that ties it in to supporting the kind of services that will ease pressure on the NHS. Councils rightly argue that keeping older people well is about much more than care homes and providing a bed clearance service for their local hospitals. It's about wellbeing in the widest sense of the word, and the NHS's provision of community services like stroke rehabilitation also have a significant role to play.

In some ways, NHS England chief executive Simon Stevens' sustainability and transformation plans with their objective of integrating health and social care in ways that meet local priorities are an attempt to synthesise the national with the local. Yet there is such an inbuilt conflict between a free-at-the-point-of-use NHS and means-tested social care that it is hard to see how they can continue to coexist.

It comes at a high cost to patients. When hospitals are in effect incentivised to shovel the old lady who's had a fall out of bed and off their books pronto (I exaggerate, a little), leaving her local authority to pick up the bill for getting her back on her feet, it seems the two arms of care that ought to be wrapped protectively around her are instead locked in a standoff. It is more arm-wrestling than hand-holding.

The government now promises (another) green paper on paying for social care in the autumn. But successive plans, each of which points to more central government funding, have crashed and burned on the runway. Oh, for a Bevan (and a Clement Attlee) with the courage and determination to sort it out.

Anne Perkins is a leader writer
Topics

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What we need is a national social care service | Anne Perkins

# data[].attributes.attachment_link.description
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The new health and care system becomes fully operational from 1 April to deliver the ambitions set out in the Health and Social Care Act. NHS England, Public Health England, the NHS Trust Development Authority and Health Education England will take on their full range of responsibilities.

Locally, clinical commissioning groups - made up of doctors, nurses and other professionals - will buy services for patients, while local councils formally take on their new roles in promoting public health. Health and wellbeing boards will bring together local organisations to work in partnership and Healthwatch will provide a powerful voice for patients and local communities.

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The health & care system: reduced size version The health & care system: full size version
The role of the Department of Health in the new system

The Department of Health's purpose is to help people live better for longer. We lead, shape and fund health and care in England, making sure people have the support, care and treatment they need, with the compassion, respect and dignity they deserve. The new and changing health and care organisations work together with the Department to achieve this common purpose.

We enable health and social care bodies to deliver services according to national priorities and work with other parts of government to achieve this. We set objectives and budgets and hold the system to account on behalf of the Secretary of State.

The Secretary of State for Health has ultimate responsibility for ensuring the whole system works together to meet the needs of patients and the public and reflect their experiences.

What the changes to the health and care system mean for patients and local communities

Most people won't notice any immediate difference to how they get the care they need: they will still contact their GP when unwell, or their local council with ongoing personal care needs, and they will continue to receive healthcare free at the point of need just as before. However, some important underlying changes are being made to how the health and care system is run.

These changes are about giving local communities and patients more say in the care they receive and doctors and nurses more freedom to shape services to meet people's needs, to improve the quality of the support, care and treatment we all receive.

For instance:

greater direct control over planning and commissioning means that doctors, nurses and other health and care professionals can better shape what kind of support, care and treatment is available locally

more emphasis on preventing illness and helping people stay independent in older age or disability means we can improve everyone's long term health and wellbeing

more power devolved to local groups and organisations means that communities now have more influence than ever over how their local health services support them

opening up to a wider range of health care providers, including independent and charitable organisations, means that there will be more choice for patients and greater pressure on services to improve

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Clinical Commissioning Groups (CCGs) are made up of doctors, nurses and other professionals who use their knowledge of local health needs to plan and buy services for their local community from any service provider that meets NHS standards and costs - these could be NHS hospitals, social enterprises, voluntary organisations or private sector providers. This means better care for patients, designed with knowledge of local services and commissioned in response to their needs.

Health and wellbeing boards in every area ensure that services work together to respond to communities' needs and priorities. They will involve people and community organisations, including elected representatives, in deciding what services the community needs - this will inform CCGs and local authorities when they commission services.

Local Healthwatch, which are represented on health and wellbeing boards, give patients and communities a voice in decisions that affect them. Local healthwatch will report their views and concerns to Healthwatch England so that issues can also be raised at a national level.

Local authorities commission care and support services and have a new responsibility to protect and improve health and wellbeing. They use their knowledge of their communities to tackle challenges such as smoking, alcohol and drug misuse and obesity. Working together with health and care providers, community groups and other agencies, they prevent ill health by encouraging people to live healthier lives.

How health and care organisations will work together nationally

NHS England supports NHS services nationally and ensures that money spent on NHS services provides the best possible care for patients. It funds local clinical commissioning groups to commission services for their communities and ensures that they do this effectively. Some specialist services will continue to be commissioned by NHS England centrally where this is most efficient. Working with leading health specialists, NHS England brings together expertise to ensure national standards are consistently in place across the country. Throughout its work it promotes the NHS Constitution and the Constitution's values and commitments.

Public Health England provides national leadership and expert services to support public health and works with local government, the NHS and other key partners to respond to health protection emergencies.

The NHS Trust Development Authority supports NHS trusts to improve so they can take advantage of the benefits of foundation trust status when they are ready.

Health Education England makes sure the healthcare workforce has the right skills and training to improve the care patients receive. It supports a network of Local Education and Training Boards that plan education and training of the workforce to meet local and national needs.

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The Health Research Authority works to protect and promote the interests of patients and the public in health research.

The Medicines and Healthcare Products Regulatory Agency makes sure that medicines and medical devices work and are safe to use.

The Human Tissue Authority regulates human tissue, such as donated organs, to ensure it is used safely and ethically, and with proper consent.

The Human Fertilisation and Embryology Authority regulates fertility treatment and the use of embryos in research.

Most health and social care professionals must be registered with one of the independent regulators, such as the General Medical Council, who help protect patients and public by ensuring that professional standards are met.

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[Withdrawn] [Withdrawn] The health and care system explained

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The new health and care system becomes fully operational from 1 April to deliver the ambitions set out in the Health and Social Care Act. NHS England, Public Health England, the NHS Trust Development Authority and Health Education England will take on their full range of responsibilities.

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