Monthly Archives: January 2016

Unhealthy survivors and the A&E crisis – why NHS managers should pay more attention to local healthcare inequalities

A&E admissions keep rising due to the “unhealthy survivor” effect. Rather than dying prematurely, people are surviving longer, accumulating chronic illnesses – and going to A&E. The A&E crisis is thus partly a consequence of medical and social success – more effective hospital treatment, better prevention and management of disease, improving living conditions and health behaviours.

But the A&E crisis is also a consequence of social inequality. Poorer people are more likely to attend A&E than richer people. Richer people tend to be healthier survivors. They are more likely to enjoy what epidemiologists call “compression of morbidity” – i.e. to live a long and healthy life, followed by rapid decline and death. The poorer you are, by contrast, the more likely you are to spend many years of your life staggering under the burden of multiple, severe illnesses – placing you at greater risk of repeated A&E admission. Much of this illness is preventable, and many A&E admissions could be prevented by improving the co-ordination of care between hospital and primary care settings, and reducing inequalities in the quality of care.

The social gradient

The statistics are striking. Allowing for age and sex, people living in the most deprived fifth of neighbourhoods in England suffer nearly two-and-a-half times as many preventable emergency hospitalisations as people living in the least deprived fifth. These are emergency admissions for long-term conditions – such as dementia, diabetes, respiratory and cardiovascular diseases – that could be prevented by more effective primary care or outpatient care. And this is a problem affecting everyone in society, not just the poorest. There is a “social gradient” in A&E admissions, whereby the further down the social spectrum you go, the greater your chances of suffering an emergency hospitalisation.

Social gradient in preventable hospitalisation. Source: Richard Cookson, based on data from our NHS inequalities research cited below

As the graph shows, preventable emergency admissions would be nearly halved if everyone had the same rate of A&E admissions as the least deprived in society. In other words, nearly half of emergency hospital admissions arise from social inequality.

Pressure on the NHS

In our recent research on NHS inequalities, my colleagues and I at the University of York and elsewhere estimated that social inequality was associated with more than 158,000 preventable emergency hospitalisations in England in 2011/12 and nearly 38,000 deaths from treatable conditions.

Preventable emergencies like these are putting huge pressure on the NHS. The pressures are likely to increase in future decades, as health and social care continue to absorb an ever larger share of public expenditure due to cost-increasing medical innovation, people living longer with multiple illnesses, and wage inflation in a labour-intensive industry. The NHS thus needs to develop new approaches to dealing with these pressures if it is to survive in its current form as a universal and comprehensive tax-funded health system.

The aspiration of proactive co-ordinated care

The NHS is good at providing equal access to reactive care when people suffer a health emergency. But it needs to get better at providing proactive care to people before they suffer an emergency. This is mostly about prevention and disease management in primary and community care settings, but hospitals can also play an important role. For example, hospital patients at risk of repeated emergency admission may need following up to check they are taking their medicines appropriately, or being cared for appropriately in the community, or being given appropriate advice and support to change their health behaviour.

Successive governments have correctly identified that the NHS needs to improve the co-ordination of care between specialties, between primary and hospital settings, and between health and social care. Current initiatives such as the Better Care Fund, new models of care and the Vanguard sites are thus all steps in the right direction. But there is a world of difference between setting policy aspirations and delivering measurable, beneficial improvements for patients.

Healthcare equity indicators can help

Generally speaking, people at the very top of society are the best at co-ordinating their own care – they have the best information, the best support networks from family and friends, the nicest home environments in which to recover from illness, the sharpest elbows. Everyone else – including people in the middle, as well as the most deprived – needs proportionately more help. So to deliver co-ordinated care more effectively, managers need better information about healthcare inequalities within their local area. To help provide this information, we have developed health equity indicators for the NHS.

We applied these indicators retrospectively to the NHS under the Blair/Brown government in the 2000s. We found that investments in GP services led to improved primary care for all socio-economic groups, particularly among the poorest, between 2004 and 2011. There was, however, only a modest reduction in inequality in preventable deaths and admissions through A&E. If NHS England were to start producing our indicators on an up-to-date annual basis, this would help managers address this problem more effectively. It would also help monitor the healthcare inequality duties introduced in the Health and Social Care Act 2012 and inform the public about healthcare inequalities within their local area.

Of course, the NHS cannot solve the problem on its own. A&E pressures are partly a barometer of wider social ills, and cannot be dramatically reduced unless Britain becomes more equal. Wider action is needed by social services, education services and other public services that impact on people’s health. Action is also needed to change people’s health behaviour – for example, through taxation, regulation and “nudges” to reduce consumption of tobacco, alcohol and sugar and to encourage healthy habits such as physical activity. More fundamentally, action is needed to reduce the inequalities in childhood circumstances that help to generate lifelong inequalities in health. The need for wider action on inequality, however, should not be used as an excuse for inaction by the NHS.

Reducing healthcare inequality is a matter of social justice. Since the NHS is under such severe pressure from preventable emergencies arising from social inequality, it is also a matter of common sense.

Disclaimer and further information:

The views in this blog are my own, and do not necessarily reflect those of the NHS or the NIHR who are currently funding my research.  Further details of the research mentioned in this blog can be found on this NHS equity indicators research project page.