We need clearly to differentiate health
care inequality from health inequality. Much mischief has arisen from the misnomer "National Health Service" as opposed to "National Health
care Service" (
Iona Heath, 2007). Attempting to use the resources of the NHS to create health has denied resources to those whose health is most unequal, the sick.
Healthcare professionals must be clear to government that health and health outcomes are influenced more by every government department other than the Department of Health, and that they cannot abdicate their responsibility for health by medicalising the population.
There are, for example, questions of overtreatment, such as whether the benefit of statins (which should be but probably are not prescribed preferentially to the less affluent) outweighs the opportunity cost of treating the sick and whether such strategies inadvertently absolve other sections of society of their responsibilities to improve living standards.
The importance of universal access to healthcare gets a mention in the
WHO report on the Social Determinants of Health. Universal access in the UK through the NHS is now under threat. GPs used to be relatively free to meet the reasonable healthcare needs of their patients. This freedom (and therefore healthcare equality) is now endangered by these emerging factors amongst others:
- consumerism
- intolerance of risk
- intolerance of complaints
- "awareness" campaigns
set against:
- limited total NHS budget for an ageing population with more complex healthcare needs
- relative underfunding of general practice
- an increasing expectation for the NHS in general and GPs in particular to address social needs
Yes, timely access for all is important, but we must ensure that measures to improve access actually do benefit those most in need rather than increase competition for access for those in greatest need and most able to benefit from healthcare.
Closely allied to health inequality is inequality in health literacy. This has a very direct impact on how effectively health services are accessed. GPs have more than enough to do to be able to provide health literacy education, but as a profession - and even as a network - GPs represent an enormous resource of expertise for schools and communities looking to improve health literacy.
Having worked in areas of greatly differing healthcare needs, my perception is that funding policies (which determine for which conditions treatment should be funded by the NHS) are more stringent and more strictly enforced in areas of lesser healthcare need. We must, therefore, take care not simply to fund areas of greater healthcare need equitably, but ensure that every pound is spent just as effectively, regardless of postcode.
So what could general practice do to reduce health inequalities?
- Maintain pressure on government and society to retain responsibility for health
- Question medical treatment of the normally well
- Evaluate equality of measures to change access to GPs
- Facilitate debate on acceptable levels of risk rather than "safety"
- Provide better support for colleagues who receive complaints (more assertive if appropriate)
- Champion the healthcare needs of the disadvantaged and ignore "awareness" campaigns relating to those with lesser need
- Continue campaigning for better resourcing of general practice
- Resist calls for non-healthcare interventions to be delivered using healthcare resources
- Support health literacy across all ages
- Champion equity of commissioning decisions especially where health inequalities exist
