Equity Choice Capacity and Culture

Transcript of Speech by Rt Hon John Reid, Secretary of State

New Health Network Conference

7 November 2003

Today in developing my theme of equity of access to health care I want to look at one simple question:

“How we can best place real power – the power of making real choices about health treatment and exerting real influence over those choices – in the hands of the many in this country inside the NHS, rather than the minority?” In its premise that question contains in itself a few provocative and interesting questions.

I want to address these questions in three ways.

Firstly, I want to explore some of the problems that we have had in translating the principle of equity of access into practice.

Secondly, I want to demonstrate some of the ways in which we are addressing that question by developing the policies and practice on empowerment for patients

Thirdly, I want to show how the modern policy of empowerment will help entrench the basic value of equity of access, which is so important in any fair healthcare system.

The starting point for me is that our basic values dictate that the use of services by patients should depend, so far as is humanly possible in our system, only on the need of patients for treatment and not on factors that are irrelevant to that need such as how much money they have. Obviously, for as long as there are inequalities of wealth in society and of income, then any health service that involves payment at the point of delivery by definition will inevitably lead to great inequality of access. Put simply, if access to health care depends upon money then those with more money inevitably get the better access to health care.

But even within a system as fair as the NHS, not everyone has benefited equally. For the centre-left there are some important philosophical issues here. In the past the goal of ‘equality of access’ has been seen as trying to get everyone ‘the same’ service. The idea that ‘sameness’ leads to equality has been seen often as the goal of policy in health. And at first glance this seems to make sense – treating everyone the same MUST provide equality, or so it may seem.

But it doesn’t. This approach has led to some old fashioned thinking by what I’d call the old left having to defend a one-size fits all approach to service delivery. And so, for the old left, anyone who attacks that approach recommending sameness must by definition be attacking the idea of equity and therefore must be right wing.

That argument is based on a fallacy, compounded by muddled thinking and contradicted by the evidence. Sameness of service has self evidently not created equality of outcome because people have different needs, and different attributes. Let’s look at four different ways in which human beings are different from each other.

First, gender. It makes no sense at all to treat men and women as ‘the same’ in health terms – in fact it would be a dangerous as well as rather difficult thing to do.

Second, race or ethnic origin. It makes no sense to treat people for instance with a high risk of blood diseases as if they were the same as people without that high risk.

Third, age – treating older people the same as younger people makes no sense when their needs are so self evidently different. Different age groups will have different needs in terms of access to treatment, information provision and support.

Fourth, disability. A person with a disability in addition to their different health needs may also need different kinds of help to access the NHS for their mainstream health on equal terms.

Fifth, socio – economic status. Patterns of disease are very different across blue and white-collar workers. Different life experiences create different health needs.

Therefore, it is self evidently true to me that if we aim at equality of outcome, by taking into account all of the major themes of disadvantage, we need more differentiation of services, not less. We need less sameness, not more.

This issue goes to the heart of policy and values for the NHS. The way we have been delivering NHS health care up until now has benefited everyone, but not to equal degrees. We have not succeeded in delivering equity of access or outcomes. Today the LSE is publishing a paper by Anna Dixon and Julian Le Grand that reviews the evidence on equity and the NHS. In particular it reports on a large body of research containing studies that focus on access and utilisation of a particular service by different social groups. Because these are studies about specific procedures they cannot be simply read across for the entire NHS – but they do portray a series of very specific pictures.

In coronary care the weight of evidence relating to the treatment of coronary heart disease suggests that admissions, rates of investigations and revascularisation do not match the higher levels of need experienced by the most disadvantaged groups compared with more affluent groups. In particular a study in Yorkshire found that affluent achievers between 65-74 years old had 40% more heart bypasses and angioplasties than those in a group of “have-nots”. It is true that all these studies predate the development of the National Service Framework for CHD and the consequent investment, but this on its own is unlikely to overturn inequity on this scale.

For elective surgery there is strong evidence that that lower socio-economic groups use services less in relation to need in diagnostic and surgical care, elective procedures for hernia, gallstones, tonsillitis, hip replacements and grommets. Indeed hip replacements were 20% lower among lower socio-economic groups despite around a 30% higher need. For preventative services, there are also inequalities. People aged between 16-44 from social classes 4 and 5 have 10% fewer consultations with their GP for preventative care, compared with social classes 1 and 2. For cervical screening ‘affluent’ health authorities had a 99% success rate of GPs meeting their screening target, with a 76% rate for less affluent health authorities For chronic diseases, research identified problems for the disadvantaged with late presentation to specialist care of chronic diseases and a higher drop out rate of treatment.

Traditionally all this has been termed ‘inverse care law‘ which observes that areas which are poorer and have greater health care needs are less well served by the health service than wealthier and healthier areas. So we have recognised this through needs factors in the new formulae for the distribution of monies to Primary Care Trusts. For the first time, the allocation formula takes account of ‘unmet need’ – to reflect the fact that we know certain groups within the population do not receive the same level of healthcare services as others with similar health characteristics.

But these inequalities also have causes, which go beyond the distribution of resources. Middle class people may get more out of the health service because they are more articulate, usually more confident and more persistent. There are a variety of cultural reasons for this. For example higher socio-economic groups are more likely to have health professionals in their family or social networks. It is not that these contacts are in any conscious or forward way used to fiddle the system for some people, but they are a source of “on-tap” advice and encouragenment on how to work the system.

A second factor is that middle class patients may be better educated, more articulate, more confident – thus better able to describe their own problems, their own medical ailments and their own symptoms which in turn facilitates a diagnosis, and access to treatment. Patients from lower socio-economic groups may have lower levels of health literacy skills.

Moreover, patients from poorer areas tended to self manage ill health because of low expectations of the health services or a lack of awareness of treatment possibilities. In some studies they had a fatalistic view of their illness that was not shared by people from higher socio-economic groups who tend to be more persistent in getting treatment.

At the moment it would appear that some people gain better access to services in the NHS because of these cultural factors. So, it follows, if we are concerned to achieve an equitable approach to health care then we must change the way in which we deliver our services. The aim and the challenge of the NHS must be to empower everyone to gain the services they need. That’s one of the reason why since August, we have engaged in one of the widest consultations about choice, empowerment and equity.

In the South West, Primary Care Trusts have opened up the debate with a wide range of stakeholders including groups of new mothers, young people, mental health users and carers, people with diabetes, heart disease, people with disabilities and local age concern groups.

As one strand in the consultation we have set up eight Task Groups that have been working since September on options for extending choice throughout the NHS

These are expert groups precisely because each group includes a majority of patients, carers and users, as well of course as NHS managers and clinicians. I feel confident that when its fully developed, our policy will meet the genuine patient need for a more sensitive health service. And I also believe that this can only be achieved by empowerment of patients throughout the patient journey.

Sometimes these are very simple or mundane things. I want to suggest to you, for instance, at the moment most medical correspondence that takes place about a patient is sent from consultant doctor to doctor. The doctor sometimes then informs the patient about what has been written about them.

But it seems to me that in an NHS which genuinely places the patient at the centre this is obviously wrong. The patient should be more informed, more of an expert on his or her own health. The NHS will have to share a great deal of knowledge with patients, users and carers so that they are informed and better equipped to use that knowledge.

Why shouldn’t letters be sent to the patient from the consultant or the doctor to ensure that they are the first port of call for information about their health? I am not suggesting that we’ve come to that conclusion but I am asking the question. Why not? Why shouldn’t we ask that they write to the patient? Of course the patient will want to go and see their own doctor to discuss, confirm, enquire about the communication, and of course the other doctors concerned should have a copy of the letter.

Medication has also been discussed in the consultation. Of course, there are very few patients in a position to correctly diagnose what drugs they should be taking at the beginning of any condition. But, if a patient has a chronic condition, they can develop a clearer understanding not only of the condition but also of the effect of different drugs on their whole body. Our expert patient scheme develops this point. People with chronic conditions develop personal knowledge about their medication which doctors must take into account when developing their long-term patient’s medication.

There is further evidence that direct involvement of the patient in the selection of their medication leads to benefits. If a doctor spends time talking about the risks and benefits of different possible medications then we know from evidence that the patient is more likely to finish the whole set of prescribed drugs. Since the point of prescribing drugs is to actually get people to take the full course, this direct patient involvement has an impact on that goal.

These may seem dreadfully mundane and unexciting things and it is undoubtedly the case that all three of them are happening in some parts of the NHS. They are already happening, not because of some fad of patients, but because they have a very good impact on medical outcomes.

So our aim of a national health service which is fair to all of us, but increasingly personal to each of us is not just a matter of meeting ambitions and expectations of today’s public and patients whose expectations are higher than previous generations – it is also a vital part of giving everyone the chance of better health for themselves and their families.

I accept that, although easy to say given established work patterns and culture in the NHS, although it is easy to say given established work patterns in the NHS, these changes are not easy to make. We therefore have a challenging road ahead of us.

And there are other things that we can do to support patients to manage their treatment and interaction with our health services. Better and easy access to the right information at the right time to help patients and users to navigate their way through the health system. We have to ensure that our services are flexible enough to support people in the reality of their everyday life. Some steps are already being taken – Ebooking, improved working times, walk-in centres, elective choice pilots are all issues under discussion in the choice consultation.

What has all this got to do with addressing the inequity of access I outlined in the first section of this speech? Throughout my own political career and central to my political philosophy I have always believed that power was the secret to greater equity. There were those that said we should educate people before we gave them the vote. But it was always going to be the case that when they were given the vote, people would educate themselves.

Give patients more power and they will make sure they, all of them, get the health service they deserve.

So what these innovations do in the delivery of health care is empower patients – not in some abstract way but in a direct relationship with their own treatment and health care. At the moment in each of these examples there are some patients who are empowered by them already. If such innovations became the norm in the NHS then they would empower all patients. And what is true for a few today, will become true for the many in the future.

That is my answer to the question of choice. Lack of power has always been linked to inequity. It is the same in health care. Choice is nothing as long as it remains theoretical. It is mere rhetoric unless it is rooted in reality, practical in its implication and underpinned by the resources, the information and power, in the hands of the person you are offering choice to, to make it meaningful. That is why I believe that empowering patients is directly linked to the issues of inequity. Only if we empower all patients can we realistically aim for the goal of equity.