Inequalities in health care

Monday 12th December 2022

Dr Andy Guise
School of Life Course and Population Sciences
Who gets COVID-
19 Vaccines?
Health inequalities are avoidable
differences in health status between
groups, populations or individuals,
arising from unequal social
conditions
 AIR AIR
POLLUTION POLLUTION
IN LOW IN LOW
INCOME INCOME
AREAS AREAS

Asthma

Asthma
https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/health-inequalities
Public Health England 2017
Causality?
 Health inequalities are the
preventable, unfair and unjust
differences in health status between
groups, populations or individuals
that arise from the unequal
distribution of social, environmental
and economic conditions within
societies, which determine the risk of
people getting ill, their ability to
prevent sickness, or opportunities to
take action and access treatment when
ill health occurs.

(WHO, 20008) (NHS and Public Health England,

2021)
 Health is biology +
Individual choice Individuals can shape, and are Society
shaped by their society (Agency
(agency) creates structures, and structures (structure)
create and limit agency)

Freedom, The possibilities for any individual or Discrimination,

group at any given time are limited
rational choice by particular social and historical violence and
and meritocracy conditions (‘choice’ can be shaped, history
or constrained, or denied)

(Hayek, Friedman) (Bourdieu, Crenshaw, Fanon, Mol, (Marx, Foucault)

Said, Sen, Smith)

FREEDOM CONSTRAINT OPPRESSION

Learning outcomes for this lecture
(what we have just covered – which is largely revision)
Describe some core trends in health inequalities in the UK (partly a
reminder of Stage 1 and other stage 2 material)
Recognise the general framework of the ‘social determinants of
health’ for thinking about health inequalities

(to come)
1 explore some specific experiences of inequalities in health care
2 understand some responses to these inequalities
3 reflect on inequalities for health care providers
 Q – why does the NW of England have
Liver disease in the UK the highest rate of years lost to liver
disease?
Variation in rate of
years of life lost from
chronic liver disease

http://tools.england.nhs.uk/images/LiverAtlas17/atlas.html The Lancet 2021 3971770-1780DOI: (10.1016/S0140-6736(20)32396-5)

1 inequalities in health care
There can be
inequalities in health
care access and use,
which causes or
exacerbates health and
social inequalities

(Health care can also

address or prevent
health inequalities –)
 1 Is health care available?

2 Can it be utilized?

3 Is it effective?

Gulliford et al (2002). "What does 'access to health care' mean?" Journal of Health Services Research &
Policy 7(3): 186-188. https://journals.sagepub.com/doi/pdf/10.1258/135581902760082517
1 Is health care available?
 The inverse care law

“the availability of good medical care tends

to vary inversely with the need for it in the
population served” (Tudor Hart, 1971)

Mercer, S. W., et al. (2021). "The inverse care law and the potential of primary care in deprived areas." The Lancet
397(10276): 775-776. https://doi.org/10.1016/S0140-6736(21)00317-2
Availability of health care workers in
deprived areas

https://bjgpopen.org/content/5/5/BJGPO.2021.0066
McLean G, Guthrie B, Mercer SW, Watt GC. General practice funding underpins the persistence of
the inverse care law: cross-sectional study in Scotland? BJGP 2015; 65(641): 799-805
2 Can it be utilized?
Uptake of COPD care

https://www.strategyunitwm.nhs.uk/publications/socio-economic-inequalities-access-planned-hospital-care-causes-and-
consequences?mc_cid=6d5ff898e9&mc_eid=e9305afdb0
trebling of A&E
visits by people
who are homeless
The number of visits to hospital
emergency departments by
homeless people in England has
almost trebled in seven years

Kings College Hospital NHS

Foundation Trust in London saw a
1563% increase from 2010/11 to
2017/18
 The digital divide
Administrative requirements

Functioning of booking
systems and waiting lists
Core point: these barriers or costs may be the
same for everyone, but can’t be managed the same
by all, and so potentially create inequalities

https://bmjopen.bmj.com/content/bmjopen/11/10/e053440.full.pdf
3 Is it effective?
Maternal health in the UK

Between 2014 and

2016 the rate of
maternal death in
pregnancy was 8 in
100 000 white
women, compared
with 15 in 100 000
Asian women and 40
in 100 000 black
women
https://www.nhsrho.org/wp-
https://www.bmj.com/content/368/bmj.m442 content/uploads/2022/02/RHO
-Rapid-Review-Final-
Report_v.7.pdf
Summary points
• There are multiple, and often complex or subtle,
dynamics around inequalities in health care
• Inequalities relate to availability, potential to use and
quality of care
• Core dimensions of inequality relate to deprivation,
race and ethnicity but also other identities and
experiences
• Understanding inequalities can be challenging. There
can be limited data on hard to study phenomena (e.g.
why people aren’t taking up care). Or causes can be
structural (e.g. institutionalised norms) or distant
(e.g. policy decision making) or historical (e.g. long
running ideologies) or multiple and entwined (e.g.
professional career structures, with discrimination,
with historical institutional policy)
• Understanding inequalities can also be very easy (e.g.
discrimination can be obvious, digital services will
always exclude some)
2 addressing or preventing inequalities through
health care
Proportionate universalism
“Proportionate universalism is the
resourcing and delivering of universal
services at a scale and intensity
proportionate to the degree of
need. Services are therefore universally
available, not only for the most
disadvantaged, and are able to respond
to the level of presenting need.”
Marmot et al 2010
Cultural and structural competence
Paying attention to the social context of
health in clinical practice

Avoids narrow emphasis on individual

behaviour in producing health outcomes

Through cultural and structural

competence, clinical practice can find
opportunities to intervene

Stonington, S. D., et al. (2018). "Case Studies in Social Medicine — Attending to Structural Forces in Clinical Practice." New England Journal
of Medicine 379(20): 1958-1961. https://www.nejm.org/doi/full/10.1056/NEJMms1814262
For example: guidelines on inclusive health care

https://www.kcl.ac.uk/csmh/assets/recommendations-for-trans-inclusive-healthcare-v6.pdf
3 Inequalities for those delivering care
https://www.bma.org.uk/media/4487/sexism-in-medicine-bma-report.pdf
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/596945/The_class_pay_gap_and_intergenerational_worklessness.pdf
https://www.nhsemployers.org/sites/default/files/2021-09/Improving%20race%20equality%20in%20the%20NHS.pdf
Closing
 Questions, comments

andrew.guise@kcl.ac.uk
@andyguiseKCL