HEALTH SERVICES,
DEPRIVED GROUPS AND
EQUITY: UK EXPERIENCE
Julian Le Grand
London School of Economics
DEFINITIONS OF EQUITY
• Equal treatment for equal need
– Utilisation dependent only on need
• Equality of access
– Access dependent only on need.
• Equality of outcome
EXISTING INEQUITIES
• Unemployed, and individuals with low income and poor
educational qualifications use health services less relative
to need than the employed, the rich and the better educated
• Intervention rates of CABG or angiography following
heart attack were 30% lower in lowest SEG than the
highest.
• Hip replacements 20% lower among lower SEGs despite
30% higher need.
• A one point move down a seven point deprivation scale
resulted in GPs spending 3.4% less time per consultation
Sources of inequity
• Risk selection (cream-skimming). Discriminates against
high risks (old and poor). Extent in UK not clear, though
pressure on waiting lists mean that both incentives and
opportunities are there for providers. Lack of knowledge,
professional ethics and interests, and targets with fixed
time limits might counter.
• Adverse selection. Patient chooses provider on the basis of
package they offer; provider not compensated. Extent in
UK probably small.
• Preference for discrimination. Extent in UK unclear.
Sources of inequity
• Unequal family resources. Since charges
largely absent, not as much of a problem in
UK as in other countries. Also inverse care
‘law’ (areas of greatest need have worse
facilities) probably wrong.
• But travel and time costs (not distance) do
impact more on poor. Important factors: car
ownership; manual workers lose pay if take
time off work
Sources of inequity
• Unequal capacities. In UK middle class
have sharper elbows and louder ‘voices’.
Better able to communicate with doctor and
to navigate system.
• Different beliefs about (a) health states (b)
health care system. Ill poor consider
themselves less unhealthy and have less
faith in system than equally ill rich
Will extension of patient choice
make things better or worse?
Types of choice
• Choice of provider
– GP
– elective surgery (focus of current policy and this
presentation)
– chronic disease management
– mental health
• Choice of treatment (overlaps with provider choice,
especially for chronic disease and mental health)
• Money follows choice
Cream-skimming
• Clearly a potential problem (Cf education). With
fixed tariff, incentive stronger than now (?). But
opportunity less if choice reduces waiting lists.
Role of consultants.
• Possible policy responses:
–
–
–
–
stop-loss insurance
No provider discretion on admission
risk-adjusted tariffs
SEG- adjusted tariffs
Unequal resources
• Transport
– How much of a problem?
Blue: 3-40
Yellow:1-3
Red: 0
Blue:200-3000
Yellow:100-200
Red:<100
Unequal Resources
Transport:
• How much of a problem?
92% of population had two or more acute NHS
trusts within 60 minutes travel time.
98% of population have access of 100 or more
available and unoccupied NHS beds . 76% to
500.
• Policy response. Support for transport costs
Unequal Capacities
How much of a problem?
No evidence that lower SEGs’ capacity for
choice less than that for voice. Indeed, some
indications to the contrary. But some
mechanism for giving advice, information
and support obviously crucial.
Policy Response: Guided Choice
Build on PCA experience in choice pilots.
PCAs in all GP practices. Responsibility for
drawing up treatment plan in conjunction
with GP, offering choices, negotiating with
providers, helping patients navigate the
system, helping ensure compliance with
treatment regimes.
Supported Choice: advantages
• Overcomes patients’ capacity problems
• Helps with chronic disease management and
treatment choice as well as choice of elective
surgery
• Uses unused skills: nurses, pharmacists, expatients
• Helps with difficulties arising from health beliefs
Supported Choice: problems
• ‘Army of bureaucrats’. But would lead to better
use of hospital capacity and a release of GPs’ time.
Latter important given GP retirement ‘crisis’ and
recruitment problem. Moreover, could be targeted
at practices in poorer areas (say,bottom quartile)
where network social capital is low.
Unresolved
• Adverse selection
• Some health beliefs