Healthcare provision as a driver for health inequality: groundless confusion or fair warning?

Picture: People ‘stacked up’ outside an Accident & Emergency department at an English hospital awaiting treatment. Could differences in the way healthcare is provided fuel inequalities in the UK? Picture reproduced with permission from Keep Our NHS Public.

The causes of health inequality in the UK have always been regarded as distinct from and largely unaffected by healthcare provision by the NHS. Here Alan Taman argues that recent changes to the NHS from marketisation could be driving health inequalities

Might differences in the way England’s NHS provides healthcare be contributing to health inequalities in the UK? This has been regarded with a degree of cynicism: health inequalities happen because of causes that bring people to needing healthcare, not the healthcare itself, according to the established rationale. The NHS was founded on principles that should mean provision is timely, freely available and universally high-quality to all, throughout the UK. Yet inequalities are increasing in the UK, at a time when the NHS in England is subject to increasing marketisation. Is this view of healthcare provision being completely distinct from the causes of health inequality still sound?

Causes of health inequality

The social causes of health inequality – systematic and avoidable health differences between defined groups – are well known and well researched, since at least the time of the 1980 Black Report (see also Marmet et al., 2001). How these can best be addressed effectively by health policies has been debated for at least as long. There is a consensus that policy has in the  main failed because it has failed to address the more overarching ‘upstream’ causes for inequalities in health that are also widely regarded as unfair and unjust. These include the structural drivers of health that reflect the physical, social and economic environments in which people live.

More recent research (Blaxter, 1997; Smith and Anderson, 2018) has also shown the importance of psycho-social factors on health inequality, and lay perceptions towards health and health inequality. In particular, the dynamic and interactive role all the causes play in driving inequalities in health – right across the social spectrum – has been emphasised.

Expert opinion, mindful of the ‘downstream drift’ apparent with policy solutions in the UK and elsewhere, has called for policies that tackle all of these causes. In particular, policies that empower people locally and facilitate collaboration between distinct agencies – such as the NHS and social care providers in the UK – to ensure downstream drift is not just recognised at a policy level but avoided. This implicitly recognises that the policy focus, in ignoring upstream causes, is driving inequality by omission: downstream efforts alone can never hope to stem or stop it.

Growing dissatisfaction with provision

There are, I suggest, several more matters to consider before the picture can be taken as complete.

Health campaigning groups in the UK have long held the view that provision of health services is increasingly under-funded and subject to marketisation which fragments and weakens it. There are widespread concerns with lengthening waiting lists for some procedures, and over whether offering some services in some parts of the country at the expense of others – the so-called ‘postcode lottery’ – is in itself iniquitous. Some Clinical Commissioning Groups (CCGs) – the NHS bodies responsible for planning and commissioning healthcare services in their local area – have recently introduced exclusion criteria governing some elective surgery based on BMI or smoking habit, turning what was a legitimate clinical criterion into a ‘tick-box’ exercise (to save money) which excludes any individual clinical judgement.1 Others have not. On the face of it, the growing suspicion that the NHS is being forced to make decisions – because of lack of funding – that are at best gravely inconsistent and at worst horribly unfair as well as iniquitous would seem to be worthy of further, careful consideration.

There is also grave concern and alarm at the potential way reorganising the NHS might yield systematic cuts or differences in provision. The current reorganisation of health services in England – as outlined in NHS England’s Sustainability and Transformation Plans and expressed with the establishment of Integrated Care Partnerships (ICPs) in some areas already – could herald in large-scale privatisation, as the current legislation opens up entire areas of provision to competitive contracts. This at the least could fragment the NHS, meaning sustained and substantial differences in provision across different regions would be very likely. At its worst, under this argument, the focus on cost saving (for profit) will lead to services being cut to the point where provision would be threatened or certainly much more variable across England than it is now.  Which would then yield systematic differences in healthcare provision completely at odds with the founding principle of free provision for all, irrespective of income.  If this is true, inequalities in provision might well increase to the point where grave differences in health outcome between different groups (based on income) are unavoidable.

An inequality engine

My own research, looking into lay perceptions of the causes of health inequality and policy solutions, has indicated that concern over provision of health services is increasingly based on direct experience of suffering, not on media narratives. My initial findings suggest that the view that differences in healthcare provision now contributes to health inequality is more than confabulation of healthcare provision and the causes of ill-health, or agreement with public discourse. Healthcare seems to be fast-becoming an engine that drives and compounds health inequalities in England. There is an urgent need for clarity on the relationships and scale of effects involved. At the same time as low- and middle-income countries are trying to develop universal systems for healthcare provision, the NHS in England seems to be moving in the opposite direction.  This is happening because of political choices – choices need to be made to stop it.

Alan Taman is currently completing a PhD on lay perceptions of the causes of health inequality and solutions at Birmingham City University. He is the Communications Manager for the health campaigning group, Doctors for the NHS. Views expressed are his own.


1 Pillutla et al. conclude by pointing out the dangers of regarding ‘personal responsibility’ as the basis for justifying this measure, with its inherent leaning towards narratives of blame and deservedness. Again, completely at odds with the founding principles of the NHS.