HEALTH SERVICES, HEALTH SERVICES, DEPRIVED GROUPS AND DEPRIVED GROUPS AND EQUITY: UK EXPERIENCEEQUITY: 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: 3-40Yellow:1-3Red: 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, ex-patients

• 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