September Special Bulletin

Inequalities and restoring equity of access as a principle for health organisations

Over summer there have been so many different channels covering health inequalities and the need for equity of access to health care and health education opportunities. Within society and within our organisations there are however difficult questions to ask about how genuine we are about establishing real equity of access to scarce healthcare resources.

When establishing a pilot mentorship scheme for women in gastroenterology over a decade ago, I was struck by the evidence suggesting that, at that time, women found it harder to access professional mentorship as a means of career support and progression. Likewise, the widening access to medicine initiatives have highlighted just how beneficial student mentorship can be in diversifying the application cohort to medical school. The truth is that social deprivation factors materially impact on life expectancy and health into older age as do many of the public health burdens such as obesity related disease and environmentally induced ill health. We have only to look at the statistics on maternal mortality and neonatal health to appreciate that these inequalities are not just socio-economic but racial, with much higher rates of maternal mortality in black and Asian women.

Writing some time ago in 2020, after the first wave of the pandemic I reflected on the impact of that national health emergency on the existing health inequalities in our system. My intention was to raise the uncomfortable truth about the real debates needed if we were committed to more equitable health care delivery and improving disease outcomes across the board.

“Inequalities in our health care system are not new. They have for the most part been ignored or hidden under politically driven reforms or targets which sometimes promote one goal by disregarding others. The negative consequences of one strategy impacting on another often go unnoticed or unrecognised. The COVID-19 pandemic highlights inequalities produced by a system where there is unlimited demand but limited supply, whether for PPE, testing, or skilled human resources. There has always been a tension when determining priorities for health service provision.

The new and uncomfortable reality is that governments and professionals alike need to be prepared to accept joint accountability for the difficult decisions that lie ahead. In the new order we will need honesty about existing inequalities in the system, and how we prevent or minimise them in the future. These inequalities, particularly of resource, exist not just between communities and care sectors but also in specialty care, and within and between medical and surgical sub-specialties themselves. There is a fundamental lack of resource in the medical workforce and this needs to be addressed.

We may need additionally to consider the previously unthinkable: placing this new order under the governance of a non-political body with a co-ordinated mandate across the UK to develop principles of care with which to inform devolved, locally responsive systems in the four nations – a co-ordinated but federated response. 

In a world where COVID-19 will be present in our communities for the foreseeable future and the next pandemic will likely occur within the medium rather than long term, our first step is to start thinking realistically about acute and chronic disease provision in a more cohesive primary and secondary care setting.

Some of the options are unpalatable. There will be colleagues who need persuading that switching things back to how they were will not serve the long term good of the services we wish to protect. The principle has to be that of “the greatest good to the greatest number”. Establishing that new balance will be challenging. 

This summer’s COVID-19 enquiry report recommendations give us all an opportunity to reflect on what we could do differently to avoid repeating strategies which further embed inequalities in our health systems.

As leaders we have a duty to support change responsibly and to ensure we focus on improved outcomes not just give lip service to the to the process of change itself. This will mean as much of a shift in behaviours and societal attitudes, as in the education and training of doctors and increased healthcare funding. Some territorial turf wars will need to be stood down and we need to examine whether we are truly committed to the utilitarian principles on which the NHS was founded. The greatest good for the greatest number will require a closer examination of how much good for how many, and with what impact on wider public health outcomes.

If we are serious about narrowing the health outcome gaps between socio- economic groups, one of the biggest debates will have to be the targeting of resources to the areas greatest need as defined by markers of social deprivation. This would help maximise the overall improvement of health outcomes for the population as a whole.

“In England, COVID-19 mortality rates were almost four times as high for those younger than 65 from the most deprived 10% of local areas.”

Health Foundation Covid -19 Impact report 2021

To optimise this public health level benefit, there would need to be a redistribution of health funding which would be both politically sensitive and challenging, in an environment where an individual’s ‘right to care’ rather than ‘the greatest good’ has become the mantra of health service provision. This is all the more reason why the depoliticising of healthcare, or at very least a cross-party, long-term strategy for health, is needed.

Clinicians need to be at the forefront of deciding what priorities need to be addressed and what systems are required to make sense of the increasing complexities of primary secondary and tertiary care of patients with multiple morbidities within an aging population. Optimising systems starts with the commissioning of care. Next up on the wish list would be an integrated IT infrastructure fit for purpose, paired with clinical autonomy in the design and delivery of both systems and of cross sector care (between primary and secondary and community). Finally, we need to commit to planning long term improvements in health outcomes, which are not dependent on the political ideology of any one government. In my view this is the only way to re-engage a weary and overburdened profession in a reinvigorated blueprint for a health system serious about reducing inequalities and increasing equity of access.