1. Professor David Gordon
Reform of the NHS:
Choice, Markets, Competition in the NHS – What Does it
Mean for Health Inequality
28th January 2006

2. 2
Health reform in England: update and next steps
The imperative for reform is urgent and growing. People
want more from their public services, to match the choice,
customer service and personalisation they can get from
their bank, supermarket or on-line shopping.
Patricia Hewitt Secretary of State for Health December 2005

3. 3
Choice in Health Care
A 2002 Harris Interactive telephone survey of 1,013
U.S. adults, which asked whether they had seen or
responded to ratings of hospitals or physicians, found
that only 1 percent of respondents had made a
decision to change health plans, doctors, or hospitals
on the basis of performance evidence
"Ultimately, choice comes at a price. As consumers,
we are expected to pay for the privilege of choice, and
if we cannot pay, we do not get to choose and, more
than likely, do not get at all," ….. "I left the U.S.
convinced that having less choice in health care is a
price well worth paying for universal coverage.“

4. 4
NHS Reforms: Choice Agenda 2006-2009
The reforms are inter-related and mutually reinforcing. There are four
connected streams of work:
•more choice and a much stronger voice for patients (demand-side
reforms);
•more diverse providers, with more freedom to innovate and improve
services (supply-side reforms);
•money following the patients, rewarding the best and most efficient,
giving others the incentive to improve (transactional reforms);
•system management and decision making to support quality, safety,
fairness, equity and value for money (system management reforms).

5. 5
New Public Management (NPM) and the Choice Agenda
NPM theory originated in the private sector
OECD & UK government are promoting NPM in the public
sector
NPM is rooted in neo-classical economic assumptions that
every person is actuated only by self-interest. From this,
everything else follows. If people are self-interested, they
have to be motivated by incentives. Different self-interests
lead to endemic conflicts.
To resolve conflicting interests efficiently, markets are best.
Self-interest and markets favour competition rather than
co-operation, and mandate hierarchy to keep people in
line. They also empty management of all moral or ethical
concern.

6. 6
New Public Management (NPM) and the NHS
The NHS could never successfully function if self-
interest became the main motivating factor for its
staff.
The Health Service works on the basis of collegiality,
co-operation and trust - what Richard Titmus termed
the ‘Gift Relationship’ (Titmus, 1970).
New public management undermines co-operation
and trust and promotes competition and vested self-
interest in their place.

7. 7
“Inequality in health is the worst
inequality
of all. There is no more serious
inequality
than knowing that you’ll die sooner
because you’re badly off” 1997
Frank Dobson,
(Secretary of state for health
1997-1999

8. 8 Age at death by age group, 1990-1995
Source: The State of the World Population 1998

9. 9
“The world's biggest killer and the greatest cause of ill
health and suffering across the globe is listed almost at the
end of the International Classification of Diseases. It is
given code Z59.5 -- extreme poverty.
World Health Organisation (1995)
Seven out of 10 childhood deaths in developing countries
can be attributed to just five main causes - or a combination
of them: pneumonia, diarrhoea, measles, malaria and
malnutrition. Around the world, three out of four children
seen by health services are suffering from at least one of
these conditions.
World Health Organisation (1996; 1998).

10. 10
30
40
50
60
70
80
1840s 90
1850s
1860s*
1870s
1880s
1890s
1900s
1910s
1920s
1930s
1940s*
1950s
1960s
1970s
1980s
1990s
Expectation of years of life, at birth
Men
Women

11. 11 Mortality of Infants and Young People, 1739-79
% Deaths among recorded
baptisms
Under 5 years Under 21 years
British Dukes
(Hollingsworth, 20 27
1965
Bedfordshire
peasants
(fairly prosperous) 24 31
(Tranter, 1966)
Lincolnshire
peasants 39 60
(Chambers, 1972)

12. 12
Longevity of families, by class and area of residence, 1834-41
District Gentry and Farmers and Labourers
professional tradesman and artisans
Rural
Rutland 52 41 38
Urban
Bath 55 37 25
Leeds 44 27 19
Bethnal 45 26 16
Green
Manchester 38 20 17
Liverpool 35 22 15

13. 13
Respiratory Digestive
Genitourinary Cancers
Circulatory Accidents

14. 14 SMRs - From the 1920s to the 1990s, men 20-64
Year SMR by Social Class
I II III IV V Ratio V:I
1921-23 82 94 95 101 125 1.5
1930-32 90 94 97 102 111 1.2
1942 88 93 99 103 115 1.3
1949-1953 86 92 101 104 118 1.4
1959-1963 76 81 100 103 143 1.9
1970-1972 77 81 103 114 137 1.8
1981-1983 66 76 100 116 165 2.5
1991-1993 66 72 113* 116 189 2.9

15. 15
Source: DoH 2003

16. 16

17. 17 The highest and lowest premature
mortality constituencies of Britain
(1991-95)

18. 18 Figure #. Standardised mortality ratios for deaths under 65 in Britain
by tenths of population by area, 1950-53 to 1999-2000
160
150
140 First
Second
130
Third
120 Fourth
Fifth
110
Sixth
100 Seventh
Eighth
90
Ninth
80 Tenth
70
60
1950- 1959- 1969- 1981- 1986- 1990- 1993- 1996- 1999-
53 63 73 85 89 92 95 98 2000

19. 19 Low Income in Britain 1961-2003

20. 20

21. 21

22. 22
Shettleston, Glasgow

23. 23

24. 24 Tackling Health Inequalities: lessons from the UK
•You need a plan and clear, measurable objectives.
•You need belief … Action needs to start with the belief that you can do
something about it.
•You need a cross-governmental plan to address health inequalities –
including the finance ministry.
•Although this work is not about health services alone, the health sector has
an important leadership role to play.
•‘Joined up government’ is very important, particularly at the local level,
where planning and funding mechanisms need to be brought into the picture.
www.who.int/social_determinants/advocacy/wha_csdh/en/

25. 25
Aims and targets
“The government’s strategy on health
inequalities aims to narrow the gap in health
outcomes across geographical areas, socio-
economic groups, age groups and different
black and minority ethnic groups, as well as
between men and women and between the
majority of the population and vulnerable
groups with special needs”
(HM Treasury and Department of Health,
2002)

26. 26
Approaches to Health Inequality Target Setting
In the European Union;
“most countries with quantitative targets have set them in terms
of reducing gaps between the poorest and the more affluent, but
Scotland and W ales appear to be unique in terms of emphasising
the importance of improving the position of the poorest groups
per se.”
In Wales & Scotland the targets do not focus explicitly on
‘closing the gap’ but emphasise relatively faster
improvements for the most deprived groups.
Source: Judge et al (2005)

27. 27 Likely health impact of socio-economic interventions
Source: Mitchell et al 2000

28. Very little of the mortality gap by social class can be
28
explained by known ‘risk’ factors

29. 29
Tackling Health Inequalities
1. The solutions?
- What can the health service do
Ending the Inverse Care law - equitable, accessible
and inclusive health care and health resource
allocation

30. 30
The Inverse Care Law
The term 'inverse care law' was coined by Tudor Hart
(1971) to describe the general observation that "the
availability of good medical care tends to vary inversely
with the need of the population served."
A primary aim of health inequalities audits and impact
assessments should be to identify the best method or
methods of allocation in order to distribute resources on
the basis of health needs and thereby alleviate the
problems caused by the ‘inverse care law’.

31. The Inverse Care Law
31
Average number of GPs per 100,000 by area deprivation, 2002 & 2004
Source: SRGHI 2005

32. Ending inequity in health care
32
· Most effective medical interventions do not reduce disease incidence risk but
may improve prognosis and quality of life through primary, secondary and
tertiary prevention.
· In order to reduce health inequalities it is essential that all segments of
society share equally in these advances on the basis of clinical needs and not be
influenced by spurious socio-demographic factors
·
Health care provision must be commensurate with clinical need and
unbiased by socio-economic status. A mismatch between need and provision is
inequitable.
· Evidence of clinical effectiveness is essential in interpreting patterns of
service provision by socio-economic status as overprovision may be as harmful
as under-provision.
· Inequity can function at various different domains such as age, socioeconomic
status, geography, ethnicity and gender. These domains may act independently or
additively.
· Inequity can occur at primary, secondary and tertiary care levels within the
NHS.

33. 33 Ten Tips For Better Health – Liam Donaldson, 1999
1. Don't smoke. If you can, stop. If you can't, cut down.
2. Follow a balanced diet with plenty of fruit and vegetables.
3. Keep physically active.
4. Manage stress by, for example, talking things through and making
time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practice safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC : airways, breathing, circulation.

34. 34
Alternative Ten Tips for Health
1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.
2. Don't live in a deprived area, if you do move.
3. Be able to afford to own a car
4. Don't work in a stressful, low paid manual job.
5. Don't live in damp, low quality housing or be homeless
6. Be able to afford to go on an annual holiday.
7. Don’t be a lone parent.
8. Claim all benefits to which you are entitled
9. Don't live next to a busy major road or near a polluting factory.
10. Use education to improve your socio-economic position

35. 35 The Origin of the Choice Agenda: NHS Safe in our Hands