Evidence that increasing social inequality in the past decade has resulted in growing inequalities in health keeps coming: but so far, despite warm words in local and national NHS plans and the Johnson government’s hollow rhetoric on “levelling up” nothing significant has been done about it.

One problem is the complexity of the task of reducing social inequalities, as a new report, seeming to offer a fresh approach at least in the Midlands, points out. 

But although the title might be off-putting, Socio-economic inequalities in access to planned hospital care: causes and consequences, researched by the Midlands and Lancashire Commissioning Support Unit (MLCSU), does as it promises. 

It seeks explanations for the fact that richer people are more likely to access NHS elective care than poorer people, and estimates the impact of this on the NHS in the form of larger numbers of emergency admissions, and suggests actions to change the situation.

The report’s readable Foreword, in stark contrast to the usual empty clichés from NHS England, is refreshingly blunt, and relentlessly focuses on the growing gap between rich and poor. It begins:

“‘Reducing health inequality’ must be one of this country’s most stable policy aims. With peaks and dips in emphasis, it has been featured consistently in policy statements since at least the late 1990s. 

“Yet outcomes have got worse. Gaps between rich and poor have widened. Defying a trend that began in late Victorian times, gains in life expectancy have stalled for poorer groups – and have even fallen for women from the poorest backgrounds. Most recently, the pandemic has exposed the radically different experiences and outcomes of different ethnic groups in the UK.”

The report comes soon after the hard-hitting reviews by Professor Mike Marmot last year highlighting the worsening health consequences of the widening gap between the richest and poorest. 

In February 2020 The Marmot Review 10 Years On, following on from the first landmark review Fair Society, Healthy Lives in 2010, warned: “The levels of social, environmental and economic inequality in society are damaging health and wellbeing.”

“… For both men and women, the largest decreases in life expectancy were seen in the most deprived 10 percent of neighbourhoods in North East England and the largest increases in the least deprived 10 percent of neighbourhoods in London.”

… “The gradient in healthy life expectancy is steeper than that of life expectancy. It means that people in more deprived areas spend more of their shorter lives in ill health than those in less deprived areas.”

Last December Build Back Fairer; the Covid 19 Marmot Review offered an even harder-hitting update on the evidence from the pandemic revealing that the inequalities impact most heavily on the BAME population:

“The links between ill health, including COVID-19, and deprivation are all too familiar. Less so have been the findings of shockingly high COVID-19 mortality rates among British people who self-identify as Black, Bangladeshi, Pakistani and Indian. Much, but not all, of this excess can be attributed to living in deprived areas, crowded housing and being more exposed to the virus at work and at home – these conditions are themselves the result of longstanding inequalities and structural racism.”

The new study, published in May by the Midlands NHS Decision Network focuses sharply on what can be done about it:

“This analysis has highlighted a problem that is directly within the NHS’s ability to control. Many of the solutions, which will be the subject of a further project, will also therefore be within NHS control. So this report identifies a problem that local services can do something about.”

The report notes previous research findings on inequalities of access to health care dating back to Julian Tudor Hart’s famous 1971 Lancet article identifying the “inverse care law,” stating that: “The availability of good medical care tends to vary inversely with the need for it in the population served.” 

In other words the greater the need (and generally the lower the income) the less health provision is locally available, while the wealthier areas with relatively lower health needs have generally much better access to high quality care. The new report does not quote Hart’s further conclusion that:

“This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”

The MLCSU report briefly refers to more recent studies that underline not only the greater access to health care of the least deprived groups, but also the negative impact of the 2012 Health and Social Care Act, which “prioritised the goal of efficiency at the expense of equity”.

To redress the balance slightly it also cites March 2021 planning guidance from NHS England which does focus on reducing health inequalities, and requires local health systems to demonstrate how they are doing this in order to qualify for additional money from the Elective Recovery Fund. 

The MLCSU research begins by highlighting the significant increases in elective treatment and outpatient attendances since 2005: elective admissions increased by 33% and outpatient appointments by 78% by 2018. Both rates of increase have been greater in the least deprived areas.

But while the improvements in waiting times between 2000 and 2014 were of more benefit to the least deprived areas, the report highlights four key factors in the more recent period of increased waiting times:

  • Access to NHS-funded private sector treatment (following the development of Independent Sector Treatment Centres and the patient choice initiative in the mid 2000s) is substantially higher in the least deprived populations, and the gap is widening.
  • Growth in rates of access to new imaging technologies tends to be slower in the most deprived areas. 
  • When the NHS seeks to limit access to certain forms of surgery (by restricting eligibility for “low value” procedures, lifestyle-based eligibility criteria and ‘referral management’), rates tend to fall more rapidly in the most deprived areas. 
  • When the NHS introduces new screening programmes, interventions resulting from those programmes tend to increase more slowly in the most deprived areas.

The authors estimate an increase of 9.7% in elective admissions is needed to ensure the most deprived groups enjoy equal access with the least deprived in each STP area in the midlands. They argue this would cut emergency admissions by 1.3% per year:

“Our analysis represents compelling evidence to support the theory that increasing access to elective care for those in the most deprived areas would lead to reductions in demand for emergency care.”

Most encouraging of all, the conclusions note that the report’s findings require a critical look at the impact of some existing NHS policies:

“… this report is sufficient to support some immediate and targeted actions. The report suggests there may be value in reviewing the policies and procedures that seek to improve or control access to elective care and the process by which decisions about treatment are taken, ensuring these processes do not inadvertently disadvantage people living in the most deprived areas.”

If it triggers even the beginnings of a serious review of some of the policies campaigners have warned about, it could be a significant step towards combatting inequalities – at least in the midlands region.

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