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Giuseppe Moscelli, Luigi Siciliani, Nils Gutacker, Richard Cookson (2018) Socioeconomic inequality of access to healthcare: Does choice explain the gradient? Journal of Health Economics, 57, 290–314.


This week’s blog is brought to you by: Dr Tim Wilson


Bottom Line

For planned vascular surgery, there is inequity in NHS provision for people living in the poorest and wealthiest neighbourhoods, representing an addressable cause of lower value.


Authors conclusion

Equity of access is a key policy objective in publicly-funded healthcare systems. However, observed inequalities of access by socioeconomic status may result from differences in patients’ choices. Using data on non-emergency coronary revascularisation procedures in the English National Health Service, we found substantive differences in waiting times within public hospitals between patients with different socioeconomic status: up to 35% difference, or 43 days, between the most and least deprived population quintile groups. Using selection models with differential distances as identification variables, we estimated that only up to 12% of these waiting time inequalities can be attributed to patients’ choices of hospital and type of treatment (heart bypass versus stent). Residual inequality, after allowing for choice, was economically significant: patients in the least deprived quintile group benefited from shorter waiting times and the associated health benefits were worth up to £850 per person.


3VH – Implications for value

The NHS was founded on the principles of need and not the ability to pay and yet, since Julian Tudor Hart first described the inverse care law, it has remained stubbornly persistent, as this

paper demonstrates. It is likely this is because we do not have a common understanding of inequity and inequalities, and without that common language, we cannot hope for a culture of stewardship to prevail.
Health inequalities are often prominent in the strategy of any NHS organisation. Yet, as we outline in our glossary,
“some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions mainly outside the control of the individuals concerned.”
This means that NHS organisations often have limited ability to influence health inequalities. But the NHS often forgets, that one cause of health inequalities is health inequities, these are defined as
“health inequalities that are systematic, socially produced (and therefore modifiable) and unfair.”

It generally means that there is enduring unfairness in the provision of care to disadvantaged groups (those from poorer neighbourhoods, from BME backgrounds, or female). The inverse care law. This paper shows us that people from poorer neighbourhoods get slower access to revascularisation surgery. They adjust for other factors and conclude that the financial impact of such a difference is worth around £850 to the individual. Having said that, targets to reduce waiting times narrowed, but did not closed, the inequity gap.

Alas, this paper is not alone. The same can be seen for:

  • Preventable hospital admissions, where living in a deprived neighbourhood means you are much more likely to have an avoidable admission.
  • NHS hip and knee replacement rates, where people living in wealthy areas are three times more likely to receive an NHS knee or hip replacement than those living in the poorest area Unpublished, more recent data puts that variation at five-fold.
  • Cardiovascular care, where access to a specialist appears to be influenced by gender, age and ethnicity.
  • Diabetes care, where poorer outcomes and diabetes control is in large part driven by the neighbourhood, racial or ethnic group you come from.
  • Health systems, not just the NHS need to systematically address inequity and a cause of inequality entirely within their gift. This means, they need to organise in order focus on whole populations, not just the one’s we see today. This is best done by creating cross organisational networks that increase value and reduce inequity.



i  Sheringham, J., Asaria, M., Barratt, H., Raine, R., & Cookson, R. (2017). Are some areas more equal than others?       Socioeconomic inequality in potentially avoidable emergency hospital admissions within English local authority areas. Journal of Health Services Research & Policy, 22(2), 83–90.

ii  Judge, A., Welton, N. J., Sandhu, J., & Ben-Shlomo, Y. (2010). Equity in access to total joint replacement of the hip and knee in England: cross sectional study. BMJ, 341, c4092.

iii Asthana, S., Moon, G., Gibson, A., Bailey, T., Hewson, P., & Dibben, C. (2018). Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. Health & Social Care in the Community, 26(3), 259–272.

iv Khanolkar, A. R., Amin, R., Taylor-Robinson, D., Viner, R. M., Warner, J. T., & Stephenson, T. (2016). Young people with Type 1 diabetes of non-white ethnicity and lower socio-economic status have poorer glycaemic control in England and Wales. Diabetic Medicine, 33(11), 1508–1515.

v Willi, S. M., Miller, K. M., DiMeglio, L. A., Klingensmith, G. J., Simmons, J. H., Tamborlane, W. V., … T1D Exchange Clinic Network. (2015). Racial-Ethnic Disparities in Management and Outcomes Among Children With Type 1 Diabetes. PEDIATRICS, 135(3), 424–434.