Equitable choices for Health
Jessica Allen Institute for Public Policy Research
Presentation at Choice, Markets, Competition in the NHS - What does this mean for health inequality? 28th February 2006
Key messages
Choice could increase inequities if it is not geared towards disadvantaged
Equitable, progressive vision of choice could reduce inequities and achieve wider benefits
White Paper makes progress, but more needs to be done
Three key messages of our report:
We want to deliver a strong message that at present choice policy risks increasing inequities.
- Wider benefits – could contribute to tackling health inequalities.
- Most of the solutions to inequity lie in primary care.
- Apply lessons from choice in secondary care to develop choice in primary care and for people with long term conditions
One of Main Drivers of Health Service Reform
- Choice – reduce waiting lists
- Choice – drive up quality
- Choice – inform engage and hand power to groups, communities and individuals.
Choice moved from being primarily mechanism to reduce waiting lists to being seen as key mechanism to drive up quality. Although talked about has engaging groups communities and individuals – bit of a leap from 1 and 2. We want to see move from 1 and 2 to 3.
"Think of the responsible parent, the informed patient, the active citizen and the dedicated teacher, nurse or local public servant who - with an extension of choice and voice, individual and collective - are taking control and driving change forward. "
Gordon Brown Feb 27 06
Inequalities in Health
Very varied life expectancy, years spent in good health
Eg gap between those born in dorset and those in Glasgow is 8-11 years (for boys) – and this has widened under labour. Although everyone is living longer. Also years spent in health – gap widening.
Relate to all sorts of things – lifestyle, living conditions, work, income, expectations and crucially and perhaps not looked at enough is also relates to access to health services
Depend partly on access to health services – inequities in health care.
Healthcare inequities
Equity founding principle of NHS but…
Health care inequity within the NHS
Social classes IV and V had 10% fewer preventive consultations than social classes I and II
Hip replacements were 20% lower among lower SEGs despite roughly 30% higher need
Intervention rates of CABG or angiography following heart attack were 30% lower in lowest SEG than the highest.
Equity is core principle of NHS – but hard to achieve
- Preventative
- Elective
- Life saving
- More GPs in wealthier areas - but mainly an issue in London
- “Affluent achievers” had 40% higher CABG and angioplasty rates than the ‘have-nots’, despite far higher mortality from CHD in the deprived group.
- A one-point move down a seven-point deprivation scale resulted in GPs spending 3.4% less time with time with the individual concerned
- Despite attempts to weight finances – seemingly intractible
- NHS compounding health inequalities that already mean if you live in a poor area you are likely to die 7 years earlier than wealthy area.
‘People in poorer families and some minority ethnic groups get less satisfactory treatment.
‘Well-informed, middle class people are often better at getting what they need.
‘Every health authority should be under a statutory duty to reduce inequities in health care provision.’
Source: Ippr Commission for Social Justice, 1994 Deputy Chair: Patricia Hewitt
Unequal access in primary care
Causes of inequity: supply
Under-doctored areas
Distance, registration
Relative quality
Professional beliefs and attitudes
Debate about causes:
Inverse care law More care you need, the less you receive. One-size-fits-all – means less specialisation in particular groups, health needs etc.
Voice
One-size-fits-all
Unequal quality
Time with GP
Satisfaction and benefit per consultation
Treatment and referral rates
More deprived areas, fewer GPs, less time with GP.
GPs struggle to manage. A one-point move down a seven-point deprivation scale resulted in GPs spending 3.4% less time with time with the individual concerned
people from minority ethnic groups are more likely than whites to: find physical access to their general practitioner (GP) difficult; have longer waiting times in the surgery; feel that the time spent with them was inadequate; and be less satisfied with the outcome of the consultation441,457. They may also be less likely to be referred to secondary and tertiary care
Social classes IV and V had 10% fewer preventive consultations than social classes I and II
Hip replacements were 20% lower among lower SEGs despite roughly 30% higher need
Unequal resources
Transport, work and personal commitments
Unequal ‘Choosability’
Capabilities, beliefs, knowledge
Inverse information law
Participation in decision-making
Equity and choosability
Patients currently inequitably involved in decisions
Pilots show equitable choosing is possible in acute sector
…but limited applicability to wider health and care choices…and lessons not being rolled out
Can’t get to see GPs – for those in worst areas, GPs in commuter centres, walk in cetnres etc – not really crack it – although definitely are of benefit to most
Participation in decisions about health leads to better outcomes
- better concordance with treatment
- Ownership of goals
- Independence
- Well-being – autonomy -> health
How can choice contribute to tackling these? Will not be a panacea but could contribute rather than exacerbate.
Equity of choice would contribute to equity of outcomes
How can choice contribute to tackling these?
Choice and Equity in White Paper
Supply
? Quantity: Under-doctored areas
Resource shift to primary care and prevention
? Quality
Commissioning and regulation
Quantity
Radical options on the supply side – new providers parachuted in
Ippr have also argued that need to encourage GPs to move into deprived areas by paying them more
Address underlying causes of under-doctoring: financial system penalises doctors in poor areas
Quality
How much switching of doctors will there be? Conflict between WP’s support of continuity and reliance on pressure of consumers. How much money will follow the patient – and how will it be weighted to their health needs?
Lack of incentives to specialise. Likely to continue one-size-fits-all?
More to do – review of nGMS formula that was abandoned – money follows the doctor
Transport
Demand:
?Work and personal commitments
??Transport to primary care
But eligibility and accessibility to transport?
But success of out-of-hours?
‘Choosability’
? Health beliefs, capabilities, knowledge?
? Professional beliefs and attitudes?
Review of information and possible support to navigate – later in the year
Emphasis on practices and commissioner choice, rather than patient choice
Equity and choosability
Access
- Need more than just commuter centres etc
- – need Drs to be paid more in deprived areas
- – culturally sensitive.
Help with transport
Information
- Information revolution in primary care
- Information, support and advocacy
- Voluntary and community sector
- Beyond performance indicators
- Health-related quality of life outcomes
- Wider factors of patient experience for personalisation
- All providers subject to same information for choice requirements
- Accessible information – languages, abilities, formats
- Not just mortality data – doesn’t measure most healthcare
Challenge for primary care will be to develop this kind of information
Support and advocacy
Need much more support and advocacy – support people to make choices and access right care and receive right care. Use of CVS and advocacy – support prescriptions
Professional attitudes
Choice will need to be informed choice if going to improve allocation and help people to make healthy choices
Professional attitudes – culturally sensitive – aware of needs – patient needs and link with deprivation.
Theory of Choice
Choice as citizen empowerment
When you start looking into choice – people talk about it in different ways
We want to see empowerment – where everybody – including the most disadvantaged and excluded are able to take advantages of supported choice – long term advantages include – better access, better consultations, improved health literacy, better health – reduction in health inequalities. There but requires investment – including support, information, support prescriptions, improved access to GPs
Challenging medical paternalism
Health care – a process of production, not (just) an item of consumption
However consumerism – active involvement in decision making – and market – incentives for providers to meet needs and preferences of patients – can bring benefits, through participation and engagement in the decision, creating a dialogue
However need to bring patient back in to patient choice so that empowerment and engagement are the drivers
Choice as consumerism
Choice as market
Choice as co-production
Key messages
- Choice could increase inequities if it is not geared towards disadvantaged
- Equitable, progressive vision of choice could reduce inequities and achieve wider benefits
- White Paper makes progress, but more needs to be done
Three key messages of our report
We want to deliver a message that at present choice policy risks increasing inequities.
Wider benefits – could contribute to tackling health inequalities.
Most of the solutions to inequity lie in primary care.
Apply lessons from choice in secondary care to develop choice in primary care and for people with long term conditions