How a universal health system reduces health inequalities

The richest fifth of people in England can expect to live at least 12 more years of life in full health than the poorest fifth. Despite their shorter lives, poorer people make more use of NHS services – especially emergency services. What is more, many emergency admissions to hospital are preventable by more effective primary care, community care and hospital outpatient care for the long-term conditions examined in this research, including anaemia, asthma, bronchitis, cardiovascular diseases, dementia, diabetes, epilepsy and Hepatitis B.

In research developing health equity indicators for the NHS, we estimated that social inequality was associated with more than 158,000 preventable emergency hospitalisations in England in 2011/12 and nearly 38,000 deaths from treatable conditions. We applied our indicators retrospectively to the NHS under the Blair/Brown government in the 2000s, and found that investments in GP services led to improved healthcare across all socio-economic groups, particularly among the poorest, between 2004 and 2011. There was, however, only a modest reduction in inequality in preventable deaths and admissions through A&E. 

Our research was funded by the National Institute for Health Research, and the research team included Richard Cookson, Miqdad Asaria, Shehzad Ali, Brian Ferguson (Public Health England), Robert Fleetcroft (University of East Anglia), Maria Goddard, Peter Goldblatt (UCL Institute for Health Equity), Mauro Laudicella (City University London), Rosalind Raine (University College London).

Our research also found that the most deprived fifth of neighbourhoods in England suffer nearly two and a half times as many preventable emergency hospitalisations as the least deprived fifth, allowing for age and sex.  This problem affects everyone in society, not just the poorest.   There is a “social gradient” in A&E admissions, whereby the further down the social gradient you go, the greater your chances of suffering an emergency hospitalisation.

Preventable emergencies are putting huge pressure on the NHS. This pressure is likely to get worse in future decades, as health and social care continue to absorb an ever larger share of public expenditure due to cost-increasing medical innovation, people living longer with multiple illnesses, and wage inflation in a labour-intensive industry. Pressures from social inequality may also increase, if recent trends towards greater wealth inequality continue.  

Producing our indicators on a routine, up-to-date basis could help NHS and local authorities improve the co-ordination of care between specialties, between primary and hospital settings, and between health and social care. To co-ordinate care effectively, managers need better information about healthcare inequalities within their local area. Proactive co-ordinated care sometimes requires paying closer attention to socially disadvantaged people, since advantaged people are often better able proactively to care for themselves – they have better information, better support networks from family and friends, nicer home environments in which to recover from illness and sharper elbows. Better information will help health professionals identify who is at risk of preventable admission and follow them up proactively. It will also help managers learn lessons from similar local areas doing well or badly at tackling preventable hospitalisations arising from inequality.

Of course, the NHS cannot solve the problem on its own. A&E pressures are partly a barometer of wider social ills, and cannot be dramatically reduced unless Britain becomes more equal. Wider action is needed by social services, education services and other public services that impact on people’s health. More fundamentally, action is needed to reduce the inequalities in childhood circumstances that help to generate lifelong inequalities in health. The need for wider action on health inequality, however, should not be used as an excuse for inaction by the NHS on healthcare inequality.

Reducing healthcare inequality is a matter of social justice. It is also a matter of common sense, at a time when NHS A&E services are under such severe pressure from preventable emergencies arising from social inequality.

Disclaimer

The views expressed in this research are those of the authors and not necessarily those of the NHS, the NIHR, the HSCIC or the Department of Health.

References

• Asaria, M, Ali, S, Doran, T, Ferguson, B, Fleetcroft, R, Goddard, M, Goldblatt, P, Laudicella, M, Raine, R, Cookson, R. (2016). How a universal health system reduces inequalities – Lessons from England. Journal of Epidemiology and Community Health
• Asaria, M, Cookson, R, Fleetcroft, R, Ali, S. (2016). Unequal socioeconomic distribution of the primary care workforce: whole-population small area longitudinal study. BMJ Open   

Further details:

• Health Equity Indicators for the NHS