‘At the heart of public health in contemporary Britain is a paradox. Britain is now collectively healthier than it has ever been in its history… Yet at the same time, the problem of health inequalities remains stubbornly ubiquitous’ (Graham and Kelly, 2004: 1).

One of the biggest problems of inequality in Britain today is the Health Gap; that those of a higher socioeconomic status are likely to both live longer and enjoy better health than persons of a lower socioeconomic status (Giddens, 2006:272). The concept of socioeconomic status refers to an ‘array of factors such as income level, education, housing, power and social status’ (Taylor and Field, 2003:45). Recent government statistics show a gap of ten years in life expectancy between those in the local authority with the lowest and highest life expectancy (Direct Gov website, 2008) and this is likely to be a conservative estimation, as this gap is increasing: whilst the health of the population as a whole is improving, the health of those at the bottom is not improving at the same rate and ‘in some cases worsening in absolute terms’ (Graham and Kelly, 2004: 1). It is not just the potential life lost that is of concern but also health quality throughout life, as stated by Davey Smith ‘inequality may make people miserable long before it kills them’ (Taylor and Field, 2003: 49). This is not a problem confined to the lower social classes, but is something that should be of concern to everyone in Britain; to quote Marmot, ‘it affects not ‘them’, but all of ‘us’. Wherever we are in the hierarchy, our health is likely to be better than those below us and worse than those above us’ (Marmot, 2004:4).

This project acknowledges that there is likely to be a complex interplay of a range of causal factors, including cultural, material and environmental. However the concern of this project is how the health care system itself, or more specifically the NHS, contributes to the problem of the health gap. Whilst it is not suggested that the NHS is the major cause of the health gap, it is identified as an important intermediary factor, as illustrated by the Health Development Agency’s diagram of key health determinants (See Appendix 1, Graham and Kelly, 2004: 3). Whilst responsibility for a country’s health could never lie solely with the health system, it has been argued that ‘the NHS often does little to combat inequality – and may even make it worse, by providing an inequitable service’ (Seddon, 2007: 80). Similarly Grossman’s model of health demand and production recognises the role of agency but emphasises that this is ‘within a social and economic framework which contains many factors outside the control of the individual’ (Maynard and Ludbrook, 1982: 112); healthcare is one of these factors.

Whilst not the most significant factor arguably health care is something we are most able to affect rather than people’s diet or attitude towards exercise for example: ‘The complexity of the factors contributing to health status inequalities makes it difficult to devise a clear and effective policy strategy. By contrast, the concept of equality of access to health care is a deceptively simple one’ (Maynard and Ludbrook, 1982: 100). As stated in the Black Report  whilst there are many factors to health inequalities other than healthcare utilisation, ‘Nevertheless, any [own emphasis] inequality in the availability and use of health services in relation to need is in itself socially unjust and requires alleviation’ (p68). Therefore not only is the Health Gap a social problem worthy of great concern, but the role of health services is both relevant and necessary to explore.

At the advent of the NHS it was assumed ‘that removing financial barriers to access … would promote more equitable care and thus improve the health of the worse-off in society’ (Taylor and Field, 2003: 51). Equity was a founding principle of the NHS, including the responsibilities ‘to provide equity of access to effective health care’ and ‘to work in partnership with other agencies to improve health and tackle the causes of health inequalities’ (Acheson, 1998). Despite these admirable aims it has been argued that ‘the NHS often does little to combat inequality, and may even make it worse, by providing an inequitable service’ (Smith, 2007). A review after thirty years of the NHS stated that despite the Welfare State ‘the differences in mortality rates between social classes, are if anything getting wider rather than narrower’ (Maynard and Ludbrook, 1982: 98). It has even been suggested that the working classes may have benefited more before the NHS, when health care was organised amongst the working classes themselves in the form of ‘Friendly Societies’ (Green, 1985). Eckstein argued that the pre-NHS organisation of heath care was actually ‘biased in favour of the poorest sections of the community’ in terms of the financial burden and the location of hospitals (Maynard and Ludbrook, 1982: 108).

Whilst there are some conceptual difficulties in measuring the equity of healthcare, for example defining ‘need’, and the difference between access and utilisation (Seddon, 2007: 81), evidence from the Black Report suggests that the use of services by lower social classes is less than would be expected given their poorer health status (Maynard and Ludbrook, 1982:111). Furthermore healthcare expenditure per patient is higher for socioeconomic groups I and II and decreases with socioeconomic class (Maynard and Ludbrook, 1982:111). Such evidence shows that the NHS has not achieved its aims of equalising access to health care for all (Mayard and Ludbrook, 1982: 110); this has significant implications as if it delivers an inequitable service then ‘the NHS becomes a producer of inequalities in health and part of the explanation of why inequalities are widening’ (Watt, 2008: 459).

These are not new criticisms of the NHS; unequal provision was previously commented on by Julian Tudor-Hart, among others, who termed this negative relationship between need and health care the ‘Inverse Care Law’ (1971). Given the problem of the health gap and the role of health care in relation to this, this project aims to provide a reappraisal of the Inverse Care Law: to investigate whether the law still exists today and if so whether it may still be characterised as Hart first described it. Finally the source of this inverse relationship will be considered. These aims will be achieved through both reviewing the literature and recent studies as well as conducting primary analysis of a secondary dataset to test the findings of the literature review.

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