Equity is the big casualty of health service

There is a great danger that the response to the Health Service Reform Programme, announced by the Government in June 2003, will ignore the most damning aspect of our health services: the grossly unfair, unnecessary and avoidable inequity which provides healthcare according to financial means rather than medical need. The less well-off are dying because of lack of equal access to health care, writes Dr Fergus O'Ferrall

Equity is supposed to be at the centre of health policy. In 2001 the Health Strategy proclaimed: "Equity will be central to developing policies (i) to reduce the difference in health status currently running across the social spectrum in Ireland and (ii) to ensure equitable access to services based on need."

Is this just lip service? Despite the mounting evidence of inequity and unfair access, the response so far has been cowardly and feeble.

The degree of systematic healthcare inequity was highlighted in 1999 by our Chief Medical Officer, Dr James Kiely, in his first annual report. He drew attention to the pervasive occupational class health inequalities in Irish society.

These were further documented in detail by the report Inequalities in Mortality 1989-1998 published by the Institute of Public Health in Ireland in 2001. From these reports we learn that the poorer social groups suffer more illness and die younger than better-off social groups: the "all causes of mortality rate" in the lowest occupational class is 100 to 200 per cent higher than the rate in the highest occupational class.

A further key report Inequalities in Health in Ireland - Hard Facts, published in 2001 by the department of community health and general practice, Trinity College, Dublin found, amongst many stark inequalities, these: unskilled manual male workers are twice as likely to die prematurely as higher professional men; unskilled manual workers are almost four times as likely to be admitted to hospital for schizophrenia than higher professional workers, and unemployed women are more than twice as likely to give birth to low birth-weight babies as women in the higher professional groups.

The Society of St Vincent de Paul in its publication Health Inequalities and Poverty posed the key question: "In whose interest do the health services operate?" They gave, from their vast experience of seeking to help the poor and disadvantaged, an unequivocal answer that our health services do not operate "in the interests of the poor and vulnerable".

We know that people in the lowest social income groups suffer worse health for all conditions than richer social groups. There is considerable evidence for geographic health "black spots" where there is increased mortality and illness associated with deprivation. We know that the less well off have poorer access to our health services, that too many people cannot receive medical care when they need it.

This is because they cannot afford primary care, or because they must wait in their thousands as public patients for treatment in hospital. When public patients do at last obtain hospital care it is delivered by junior doctors in a consultant-led service. Private patients enjoy a consultant-provided service.

The uniquely Irish "two-tier" system of access and care remains sacrosanct: financial means determines access to care. The Society of St Vincent de Paul documented actual cases where finance secured previously denied access to confirm what we all know from our everyday experience.

The Health Strategy 2001 admitted that the public-private mix in hospital care "raises serious challenges, which must be addressed in the context of equity of access for public patients". It is clear that the strategy proposals in this regard are a failure: the proposed elimination of waiting lists by 2004 will not occur. The measures to achieve the national goal of "fair access" either have not been taken, or will not result in fair access. This national goal - one of the four set out in the strategy - urgently needs review and a determined political effort to address it.

Lack of "fair access" means people are dying unnecessarily. For example, we know that the mortality rate for the lowest occupational class for heart disease is about 120 per cent higher than in the highest occupational class. Yet there are substantial variations in the provision of diagnostic, therapeutic and rehabilitative services for coronary heart disease with the poor having least access to such services.

The Chief Medical Officer advised in 1999 that: "All policies likely to have a direct or indirect effect on health should be evaluated in terms of their impact on health inequalities, and should be formulated in such a way that by favouring the less well off they will, whenever possible, reduce such inequalities."

In other words, as a people we must choose to change our health services to tackle inequity. A hesitant start has been made in two areas: the National Anti-Poverty Strategy (NAPS) and in the new policy approach known as Population Health.

In NAPS, targets have been chosen in relation to health status, equity of access and other areas in order to deliver some improvement before 2007. For example, there are targets to reduce the gap between the lowest and highest socio-economic group by at least 10 per cent for circulatory diseases, cancers, injuries and poisonings by 2007 and to provide equity of access to public acute hospitals and to effective primary care services by 2007. Does anyone seriously believe with current policies that these targets will be met?

Given that Ireland has a relatively unhealthy population by comparison with other countries at a similar stage of development, there is some emphasis on a "population health" approach. It was the theme of the 2001 annual report by Dr Kiely. Such an approach requires a new public consensus around agreed actions to tackle health inequalities.

In particular the community and voluntary healthcare sector is vital to a "population health" approach. Margaret Whitehead, an international authority on health equity, has stated that "equity policy requires a genuine commitment to decentralising power and decision-making, encouraging people to participate in every stage of the policy-making process". The new principle of "people centredness" was included in the Health Strategy so that new health structures "will empower people to be active participants in decisions relating to their own health".

The Health Service Reform Programme, announced in June, fails to make clear how this principle will inform the proposed new centralised national health service. I have recently argued that the community and voluntary healthcare sector, composed of more than 600 organisations, is the "sleeping giant" of a "people-centred" health service: one that is designed to identify and respond in a caring fashion to health needs. (see People Centredness: The Contribution of Community and Voluntary Organisations to Healthcare, Studies, Autumn 2003).

We need an urgent public debate on how the proposed health reforms - which will create a highly centralised "command and control" national health system - will ensure equity and fair access. That is why the Adelaide Hospital Society is organising a major public conference on "Equity and Access in Healthcare" on October 11th.

If we follow the logic of a "population health" policy approach, what we require is an "enabling health service" - one in which all involved in the provision of care, both statutory and voluntary agencies, are equipped to facilitate widespread citizen involvement. Such involvement is essential in order to equalise opportunities for access to healthcare resources and to raise the health status of all social groups.

The recent establishment of a Voluntary Activity Unit and a new Population Health Division as part of the reform of the Department of Health and Children are positive steps, but the fundamental re-orientation they imply must be widely embraced and fully developed in the new structures which are shortly to be established under the Health Service Reform Programme. We need a strong public voice to ensure that this occurs.

Dr Fergus O'Ferrall is director of the Adelaide Hospital Society

• Details of the proposed public conference "Equity and Access in Healthcare" organised by the Adelaide Hospital Society on Saturday, October 11th, 2003 are available from the society, tel (01) 4142069, email info@adelaide.ie.