Equity of access to health care services:: Theory and evidence from the UK

Social Science & Medicine 53 (2001) 1149–1162

Equity of access to health care services:Theory and evidence from the UK

Maria Goddard, Peter Smith*

Centre for Health Economics, University of York, Heslington, Heslington, York, YO10 5DD, UK

Abstract

The pursuit of equity of access to health care is a central objective of many health care systems. This paper first setsout a general theoretical framework within which equity of access can be examined. It then applies the framework byexamining the extent to which research evidence has been able to detect systematic inequities of access in UK, where

equity of access has been a central focus in the National Health Service since its inception in 1948. Inequity betweensocio-economic groups is used as an illustrative example, and the extent of inequity of access experienced is explored ineach of five service areas: general practitioner consultations; acute hospital care; mental health services; preventativemedicine and health promotion; and long-term health care. The paper concludes that there appear to be important

inequities in access to some types of health care in the UK, but that the evidence is often methodologically inadequate,making it difficult to draw firm conclusions. In particular, it is difficult to establish the causes of inequities which in turnlimits the scope for recommending appropriate policy to reduce inequities of access. The theoretical framework and the

lessons learned from the UK are of direct relevance to researchers from other countries seeking to examine equity ofaccess in a wide variety of institutional settings. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: Equity; Access; Socio-economic group; Methodology; UK

Introduction

The concept of equity of access to health care is a

central objective of many health care systems and hasbeen an important buttress of the UK National HealthService since its inception in 1948. Yet the concept

nevertheless remains somewhat elusive, and researchevidence on the nature and magnitude of inequities,although extensive, proves patchy and difficult to

interpret. As a result, it is often not straightforward todecide whether inequities in access pose a significantpolicy problem and if so, how they might best be

tackled. Many governments have made commitments totackle inequities in access but making this policyoperational will be difficult without a clear picture ofwhat is currently known about equity of access to health

care services. The purpose of this paper is therefore toset out a theoretical framework for assessing studiesrelating to equity of access to health care. The frame-

work is then used to assess recent research evidence onequity of access amongst socio-economic groups in UK.Although concentrating on the UK experience as an

illustration, the paper uses a general analytic frameworkwhich is of direct relevance to researchers from othercountries seeking to examine equity of access in a wide

variety of institutional settings (Whitehead, 1992).An extensive theoretical literature on the various

notions of equity relating to health and health care exists

(Williams & Cookson, 2000). This paper focuses onequity in the form of equal access to health care forpeople in equal need. It is important to recognise thatthis is not necessarily the same thing as equality of

treatment (for equal need) or equality of health outcome(Mooney, Hall, Donaldson & Gerard, 1991; Culyer,Doorslaer & Wagstaff, 1992; Mooney, Hall, Donaldson

& Gerard, 1992). Equity of access is purely a supply sideconsideration, in the sense that equal services are made

*Corresponding author. Tel.: +44-1904-433779; fax: +44-

1904-432700.

E-mail address: [email protected] (M. Goddard)

[email protected] (P. Smith).

0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 4 1 5 - 9

available to patients in equal need. In contrast,variations in treatment arise from the interaction

between supply and demand which depend on thepreferences, perceptions and prejudices of both patientand health care provider. Variations in health outcome

depend on many factors in addition to the receipt ofhealth care.The concept of equity of access we address is

therefore, at least in principle, an objective notion which

is independent of ethical judgement. We do not considerhere the issue of vertical equity (does access varyappropriately in accordance with variations in need?).

The issue of vertical equity is less commonly addressedand gives rise to profound issues of ethical judgement,related for example, to the extent to which an element of

efficiency should be sacrificed in pursuit of a verticalequity goal.In practice, almost all empirical studies of equity of

access, at least in the first instance, consider variations intreatment rather than variations in access and exhibitlittle or no consideration of any theoretical frameworkfor the research. In many circumstances this compro-

mises the usefulness of the results, and we believe that itis imperative that researchers in this area think harderabout the theoretical underpinnings to their work.

Section 2 therefore outlines a tentative framework whichwe found helpful for examining the results of empiricalwork.

We apply this framework in Section 3 to examine theextent to which the existing literature offers usefulevidence relating to inequities of access experienced bydifferent socio-economic groups in five health care

sectors.It is important to note that we are concerned only

with systematic inequities suffered by identifiable groups

of citizens, defined by social group. Other possiblegroupings of citizens (such as age, sex, ethnic group,geographical area) have been considered elsewhere

(Goddard & Smith, 1998). Moreover, in addition toany systematic effects, substantial ‘‘random’’ inequitymay also arise in any health care system because of

factors such as variations in medical practice andhistorical accident. We do not consider inequities arisingfrom such sources unless they systematically affect socialgroups differentially. Section 4 offers some conclusions

arising from this study, and summarises the implicationsfor policy and for future research in this area.

Towards a theoretical framework

The horizontal principle of equity addressed by thispaper is the extent to which there exists equal access forequal need. This begs the questions: what is need? what

is access? These questions lead us to consider conceptsrelated to the quality of health care and the utilisation of

health care. This section seeks to draw these conceptstogether into a unified theoretical framework. It draws

on a literature which goes back to a small number ofseminal contributions (Aday & Andersen, 1981;Vladeck, 1981).

Need

Unfortunately, as numerous authors have noted, theconcept of the ‘‘need for health care’’ is far from

unambiguous (Culyer, 1995). For example:

* does it relate to an individual’s level of illness or thecapacity to benefit from treatment?

* to what extent should non-clinical contributions toneed such as an individual’s social circumstances, beconsidered?

* how is the relevant concept of health status to bemeasured? In particular, many studies rely on self-reported illness and the predisposition to reportillness may vary systematically between groups;

* at what stage should need be measured? For example,two identical individuals may present to the healthservices with differences in immediate clinical need

because previous health care has been less effectivefor one individual than the other.

Discussion of need raises a whole host of issues

relating to individual choice and inherent healthiness, asdiscussed by Le Grand (1991). Detailed discussion ofsuch issues was beyond the remit of this study. However,

we found it necessary to consider the relevant notion ofneed at various stages in our review of empirical work.In practice, we found that many studies of inequity

have paid only scant attention to the concept of need.

One of the following assumptions is usually made:

* Levels of need are the same in each group beingstudied, meaning that no explicit consideration of

need is necessary.* Levels of need are assessed on the basis of a crude

measure, such as self-reported morbidity, thereby

assuming that there are no systematic variationsbetween groups in the way that the associatedquestion is interpreted or answered.

* Levels of need are assessed on the basis of a bio-medical measure of health status, therefore assumingthat there is no systematic variation in the way thatsuch measurements are taken and that unmeasured

factors (such as social circumstances) are not relevantto need.

* Levels of need are indicated by the characteristics of

the area in which individuals live, rather than theirown circumstances. This approach leads to potentialproblems of interpretation, as an effect observed at

the area level may not apply at the individual level(and vice-versa).

M. Goddard, P. Smith / Social Science & Medicine 53 (2001) 1149–11621150

* Need is considered to be a ‘‘latent’’ variable whichcannot be measured directly but is represented by a

set of proxy socio-economic measures, perhapsinferred from statistical analyses of utilisation ofthe whole sample under scrutiny.

* Levels of need are indicated by the results of someother study, leading to the potential for circularity inargument if that study itself is based on somemeasure of utilisation.

Clearly each of these alternatives is in some sensedeficient and gives rise to the potential for misinterpre-

tation of results. We must nevertheless assume that someacceptable operational concept of need can be devel-oped. This then allows us to envisage a ‘‘representative

individual’’ from each of the population groups ofinterest exhibiting some specified level of clinical (andpossibly social) circumstances, which we define as needs.

The interest is then in the extent to which access,utilisation, quality and outcome vary according to thepopulation group in which an individual is located.

Access

The next stage is therefore to formulate an oper-

ationally useful concept of access. As noted above, thisis a supply side issue and indicates the level of servicewhich the health care system offers the individual. The

precise formulation of the notion of ‘‘access’’ is highlycontingent on the context within which the analysis istaking place. Thus, in the US, access is often considered

to refer merely to whether or not the individual isinsured, and nuances such as the level of insurance orthe magnitude of copayments are secondary. In Europe,however, where almost all citizens are in principle

insured, access can be quite a subtle concept. It might,at its most general level, refer to the ability to secure aspecified range of services, at a specified level of quality,

subject to a specified maximum level of personalinconvenience and cost, whilst in possession of aspecified level of information.

Unfortunately few, if any, researchers have explicitlyarticulated all the components of access noted above.Certainly it is often reasonably straightforward to define

the range of services under consideration. However, it isimportant to note that the quality of service is also anintrinsic element of access which might complicate anyexamination of access. Donabedian (1980) presents three

categories of quality: structure, process and outcome. Indifferent ways, variations in each of these aspects ofquality might affect the patient. Poor quality in terms of

structure might lead to inappropriate use of health careservices; poor quality process might lead to dissatisfac-tion and deter compliance; poor quality outcomes is in

itself undesirable, and may in turn deter future users(Starfield, 1993). Clearly there is enormous potential for

quality issues } such as staff attitude, the condition ofpremises, waiting time, time spent with patients, and

clinical outcome } to vary systematically betweenpopulation groups. Yet, because of its elusive nature,few studies seriously address the issue of variations in

the quality of access.Many systems of health care are free of user charges.

However, there might be considerable variations in thepersonal costs of using services, and although seeking to

equalize personal costs of access is infeasible, there mustbecome a point when they become unacceptable (Birch& Abelson, 1993; Schafer, 1994). Similarly, although a

service is available to all individuals, there may besubstantial variations in awareness as to its availabilityand efficacy, perhaps because of language or cultural

differences. Again, to the extent that these are amenableto health service remedy, they may constitute legitimatecomponents of access.

In summary, variations in access offered by the supplyside might arise for the following reasons:

* Availability: certain health care services may not beavailable to some population groups, or clinicians

may have different propensities to offer treatment topatients with identical needs from different popula-tion groups;

* Quality: the quality of certain services offered toidentical patients may vary between populationgroups;

* Costs: the health care services may impose costs(financial or otherwise) which vary between popula-tion groups;

* Information: the health care services may fail toensure that the availability of certain services isknown with equal clarity by all population groups.

Although various indicators of access (such as

availability of resources, waiting time, user chargesand other barriers to care) might be measured, it israrely the case that the complex notion of access

described above can be observed directly. Rather, it isutilisation that is observed. In the terminology of Adayand Andersen, this reflects the extent to which ‘‘potential

access’’ is converted into ‘‘realised access’’ (Aday &Andersen, 1981). We shall assume that the decision as towhether to accept the offer of treatment, leading to

observed utilisation, rests with the individual, often ofcourse, under the guidance of health care professionals.

Utilisation

The measure of utilisation used may often beproblematic. For example, numbers of contacts with ageneral practitioner (GP) may be used as a measure of

utilisation in primary care. Yet contact rates may not bea good measure of either the quality or quantity of

M. Goddard, P. Smith / Social Science & Medicine 53 (2001) 1149–1162 1151

health care received. Indeed, in some circumstances acontact may simply reflect an administrative require-

ment, such as the need to obtain a sick note for anemployer. Similarly, measures of hospital utilisationsuch as completed episodes or bed days give rise to

problems of interpretation. Many empirical studiesfocus on utilisation of a single procedure. Yet theremay be equally effective alternative health care therapieswhich are not considered. In these circumstances, under-

utilisation may simply indicate use of such alternativetherapies. Similarly, some groups may make use ofalternative services in the private or voluntary sector and

thus variations in utilisation of public services will notgive a full picture of total use.We nevertheless assume that a satisfactory measure of

utilisation can be found. This allows us to develop aneconomic model of whether or not an individual receivescare, based on the interaction of supply of care

(represented by access) and demand for that care.Separating potential influences on utilisation into supplyand demand factors provides a useful classificationsystem which allows us to address the important issue of

the causes of any observed variations. However, werecognise that in many cases supply and demand factorswill interact in order to produce observed variations in

utilisation for a given level of need, and in such cases itmay be difficult to separate them without furtheranalysis.

A simple model of demand

On the demand side, it is perhaps simplest to modelthe treatment decision as the usual economic choice:namely, do the expected benefits of treatment (asperceived by the patient) exceed the perceived costs to

the individual? We therefore present a simple model ofdemand for health care which applies directly to the UKNational Health Service (NHS), but which is of

relevance to a wide range of alternative systems ofhealth care. It is based on the model of Goddard et al.(Goddard, Malek & Tavakoli, 1995). Before describing

the model, it is important to clarify some aspects of UKinstitutional arrangements. Most health care is deliveredby the NHS, which is funded out of general taxation,

and seeks to be a comprehensive service, generally freeto patients at the point of use. All citizens are registeredwith a GP who is responsible for delivering primary careand who is the gatekeeper to secondary care. Secondary

care is delivered by a set of NHS providers, whichprovide inpatient care (including day cases), outpatientcare (in the form of specialist clinics), and community

care (home nursing, day centres etc.). In general,patients cannot gain access to NHS secondary careunless referred by a GP, except in emergencies. There is

a small private sector that concentrates on providingroutine elective procedures to those who are insured,

and to those who choose to pay the associated fees.Most private procedures are undertaken by NHS

clinicians. Waiting times for appointments with NHSspecialists and for NHS procedures can be very long(Martin & Smith, 1999), and the principal advantage of

private health care over the NHS is generally perceivedto be the shorter waits.Now suppose that individual i has been offered NHS

care and assesses that immediate treatment would yield

a value Vi, expressed perhaps in quality adjusted lifeyears. The ‘‘price’’, both implicit and explicit, of NHStreatment can be denoted Ci (for some services this may

effectively be zero). The price of equivalent private orother non-NHS health care is Pi. For simplicity, weassume that the clinical benefits of non-NHS care are the

same as those arising from NHS care. Assuming thatPi > Ci, there must be some respect in which theperceived quality of NHS care is inferior to that of

private care if an individual is to consider seekingprivate care. Let us assume that the qualitativedifference is embodied in waiting time, so that NHStreatment can only be offered with a delay t (waiting

time), while private health care can be secured immedi-ately. This means that the benefit of NHS treatment tothe patient is reduced, as the wait imposes costs on the

individual in terms perhaps of lost earnings or furtherpain. We shall assume that for individual i the benefits ofNHS treatment reduce as t increases in line with a

negative exponential function expð�gitÞ, so that theeffective quality-adjusted benefit of NHS treatment isVi expð�gitÞ, where gi is a personal preference para-meter.

Under these assumptions, individual i has threepossible courses of action: to accept the NHS care(under which treatment may be delayed); to seek non-

NHS health care as an alternative (under whichtreatment is immediate); or to forego any health care.The following preferences will determine the health care

decision made by individual i:

* NHS treatment will be preferred to no health care if

Vi expð�gitÞ � Ci > 0.* NHS treatment will be preferred to private health

care if Vi expð�gitÞ � Ci > Vi � Pi.* Private health care will be preferred to no health care

if Vi � Pi > 0.

These preferences can be represented diagrammati-

cally, as shown in Fig. 1, which describes the decisionmade by individual i as individual valuation of benefits(V) and time preference (g) vary and all other

parameters remain constant. In area A, NHS care willbe sought, while in area B non-NHS care is preferredand in area C no health care is sought.

This model illustrates the importance of a variety offactors in determining whether a representative indivi-


dual with a given clinical need will be observed to receiveNHS care. The probability of receiving NHS caredepends on five factors, as follows:

Benefit of treatment Vi: Different individuals with the

same level of clinical need may nevertheless perceive thatthey would receive very different benefits from treat-ment, depending for example on their social and

economic circumstances (Williams, 1999). This para-meter is likely to be heavily influenced by the advice ofmedical staff. It can also be thought of as encompassing

the individual’s degree of risk aversion, so that onereason for variations in V may be variations in attitudestowards the risks of treatment.

Cost to the individual of NHS treatment Ci: Factors

such as travel costs, loss of earnings and a wide range ofother less tangible costs of seeking NHS care may varybetween individuals. Most importantly, the same nom-

inal price may have very different implications for a rich,as opposed to a poor, individual.

Quality preference parameter gi: Different individuals

may exhibit different attitudes towards a delay intreatment, or other aspects of the quality of care,leading to different propensities to seek alternatives to

NHS care.Relative quality of NHS treatment t: In the model set

out above the quality of NHS treatment is representedby waiting time t, which can of course vary between

providers and between population groups. This is merelyrepresentative of the many other aspects of perceivedquality which could be modelled similarly.

Cost to the individual of non-NHS health care Pi:Availability and costs of private and other substitutemodes of care, both within and outside the health care

sector, vary depending on the nature of the health

problem, the individual’s income, health care insurancearrangements, cultural background and local welfare

services. In particular, the relative cost of private healthcare is usually greater for the poor than for the rich.Similarly, if alternative welfare services, such as com-

munity care, are potential substitutes for NHS care, theavailability and effective prices of such care may varysubstantially between individuals.The importance of these considerations varies from

service to service. For example, in the acute electivesector, valuation and costs of state care are likely to berelatively well known, and the important determinants

of seeking care will be attitudes towards waiting timeand ability to pay for private health care. However, inthe long-term care sector, quality of care may be

perceived to be a much more complex issue, and theremay exist a larger range of alternative options.We do not suggest that this rudimentary analysis is

necessarily realistic for all aspects of public sector healthcare or for all systems of health care. It is merelyintended to draw out some of the many potentialinfluences on utilisation on the demand side. Further-

more, the model glosses over a further possible cause ofvariations in demand that may be of crucial importancein many contexts: variations in the information available

to individuals. This can be thought of as being due to adegree of uncertainty in estimating the correct values ofthe components of the model we have presented. That is,

individual decisions may vary because of imperfectionsin available information or in the ability to process suchinformation, either on the part of patients or theprofessionals advising them.

The model moreover raises an important character-istic of health care which is not well handled byconventional economic models of supply and demand

} the reliance of patients on medical advice, leading toan interaction between supply and demand. In principle,it might be convenient to think of the specialist or GP as

a disinterested agent acting and advising in the bestinterests of the patient. In practice, clinicians are alsolikely to be aware of supply side considerations, most

notably the pressure on their own budgets. For example,amongst hospital physicians there may be an incentiveto offer advice which leads to over-supply of treatment(if the marginal revenues from a patient exceed the

expected marginal costs) or under-supply (if marginalcosts exceed marginal benefits). Similarly, in UK, manyNHS surgeons also offer private health care, a situation

which offers the potential for biased advice to thepatient.This plethora of determinants of supply- and demand-

side influences on utilisation hints at the difficultiesmany studies encounter in seeking to infer from theirfindings policy implications regarding access. The

perspective of this paper is inequity in access, and thissuggests the need for an element of judgement as to what

Fig. 1. Individual choice of health care determined by time

preference (g) and valuation of benefits of intervention (V).


constitute (from an equity perspective) ‘‘relevant’’ and‘‘irrelevant’’ sources of variation in utilisation. Thus it

might be felt that what matters from our perspective isthat individuals with identical need should be offeredhealth care with the same level of quality and at the same

implicit price to the patient (essentially supply sideconcepts). Variations in utilisation arising from (demandside) sources other than these might be consideredlargely irrelevant. However, this distinction between

demand and supply considerations is not always clearcut. Variations in utilisation may arise because ofdifferences in perceptions about the availability or

benefits of treatment. These would be of relevance toinequity of access if they relate (say) to differences inclinical advice, but might be irrelevant if they are largely

due (say) to differences in patients’ attitudes towardsrisk.Furthermore, there may be circumstances in which

certain groups decline treatment which other groups use,and which is offered on equitable terms, because theyperceive the benefits to be inadequate. For example,poorer citizens may judge that, because of their poor life

chances, the benefits of a smoking cessation programmeare not sufficient to make it worthwhile participating. Ifsociety judges that it is nevertheless worthwhile seeking

to correct this unequal take-up, it may be necessary toput in place positive incentives for targeted groups toparticipate. This is essentially a vertical equity issue,

which is strictly speaking beyond the scope of this paper.It is also important to note that variations in access

may indicate inappropriately high levels of utilisationamongst some groups, rather than low utilisation

amongst others. For example, invasive surgery may beoffered more frequently to certain population groups asan alternative to more effective medical therapy. And in

other contexts, certain population groups may persuadehealth services to offer treatment that would notgenerally be considered efficient use of resources. More

generally, studies focusing on particular services (ratherthan client groups) may not capture the possibility thatpatients in low utilisation groups may be receiving

treatment from other health and welfare services,without detriment to health outcome } for example,high use of emergency services might be associated withinadequate use of primary care services, perhaps

brought about by poor access. This problem isparticularly important in the long-term care sector.Finally, routine notes of caution must be entered

about the distinction between association and causality,and the problem of confounding. Statistical analysis ofobservational data rarely offers definitive evidence as to

whether an association is causal. And confounding is aparticularly important problem in studies of equitywhich are seeking to identify whether particular social

groups receive systematically different levels of care toother groups. In practice, the usual focus of research

attention is a group suffering from some perceiveddisadvantage. Yet disadvantaged individuals often suffer

from ‘‘multiple disadvantage’’. For example, many innercities contain areas with disproportionately high num-bers of overlapping households with low income, low car

ownership, poor housing, in ethnic minorities. Suchareas may exhibit severe variations in certain aspects ofaccess to health care. However, it is often verychallenging for researchers to isolate which particular

dimension (or combination of dimensions) of disadvan-tage has led to the inequity. This limitation often makesit difficult to infer appropriate policy responses.

The potential complexity of the model of utilisationdiscussed in this section therefore means that, even ifdifferences in needs-adjusted access to health care are

inferred from a study, careful analysis may be requiredbefore a policy conclusion can be drawn. In this respect,prima facie evidence of variations in access to care can

only be considered useful for policy purposes if it ispresented in conjunction with the likely causes of suchvariations.

A review of the empirical literature on the NHS

In this section we first summarise the researchevidence on equity of access in relation to socio-economic group, bearing in mind the methodological

issues described earlier. We then interpret the results inthe light of the model, discussing the relevance of theparameters to the research findings.

Methods

A comprehensive literature search covered the period

1990–mid-1997 and focused on UK health services. Tenbibliographical databases (including medline, appliedsocial science index, econlit) were searched electronically

using key words and phrases associated with access to,and utilisation of, health care services. The searchstrategies were designed by staff from the NHS Centre

for Reviews and Dissemination at York to locatepublished material relating to equity of access to thefive service areas of interest. Examples of the search

strategies adopted are given in the full study report(Goddard & Smith, 1998). Additional material wasobtained through hand searches of the reference lists ofarticles located by the electronic searches.

We also sought out unpublished material, includingstudies in progress and those undertaken at regional andhealth authority level without intention to publish. The

Directors of Research and Development in each NHSregional office were contacted and asked to providedetails of research on this topic undertaken in their area

as well as names of those in other NHS organisationsknown to be interested in the topic. Department of


Health staff also provided leads on institutions orindividuals known to work on this topic. These were

followed up as appropriate. In addition, databases ofresearch work in progress were searched to identifyacademic studies and a number of key researchers in the

field were also approached and asked about currentwork. A request was published on the electronic healtheconomics network asking for related information.Finally, a variety of charities and professional organisa-

tions were contacted (for example, the NationalCo-ordination Team for Breast Cancer Screening).The framework outlined earlier was used as a guide

for the analysis and organisation of the empiricalevidence on equity of access amongst different socio-economic groups. Despite the huge amount of material

published on equity and access, almost every study hasused utilisation rates as a proxy measure of access. Ourreview therefore had to focus on studies measuring

utilisation and we found the quality of this researchvaried widely. In summarising the evidence, we thereforeplace greatest weight on studies which address mostadequately the methodological issues outlined above. In

particular, the results we report exclude many studieswhich fail to adjust for need in some manner. To theextent that the evidence permits, we examine inequities

in five service areas: GP consultations; acute hospitalcare; mental health services; preventative medicine andhealth promotion; and long-term health care.

Results

GP consultationsHigher rates of GP consultation are associated with

greater deprivation and with lower socio-economic

group (measured in a number of ways e.g., loss ofemployment, unemployment, non-owner occupier sta-tus, manual social class, lack of access to a car), a finding

which has been supported by studies which haveattempted to control for need (Balarajan, Yuen, &Machin, 1992; Carr-Hill, Rice, & Roland, 1986;

McCormick, Fleming, & Charlton, 1995; McCormick& Rosenbaum, 1990; Blaxter, 1984; Puffer, 1986).Replication of older studies which had suggested a

‘‘pro-rich’’ bias in total NHS care and GP utilisationhave found no evidence to support this (apart from inthe category of people who were classified as ‘‘not sick’’)once self-reported morbidity was taken into account;

indeed, evidence of a slight pro-poor distribution hasbeen suggested (Collins & Klein, 1980; O’Donnell &Propper, 1991; Propper, 1998). Recent analysis of GP

consultation rates amongst children and young peoplealso found no evidence of a social class difference(Cooper, Smaje, & Arber, 1998). The exception to this is

GP visits for preventative care as those from manualsocial groups are less likely to consult than those in

equivalent higher social classes (McCormick et al.,1995).

Outpatient care & referralsDeprivation at the practice level has been found to

have a positive impact on total number of referrals andmedical referrals and a negative impact on referral forsurgical reasons although the latter is not statisticallysignificant (Fleming, Crombie, & Cross, 1991). Calcula-

tion of referral rates per 1000 people consulting revealedno significant differences in referral rates betweenmanual and non-manual groups (Hippisley-Cox et al.,

1997). However, a study of six conditions amenable tosurgery revealed that area level operation rates matchedthe higher GP consultation rates found in more deprived

areas only in the case of varicose veins; for hernia andgallstones operations there was no relationship withdeprivation; and for arthritis of the hip, operations were

lower in the most deprived areas (Chaturvedi &Ben-Shlomo, 1995). This may suggest that althoughdisadvantaged people consult their GPs about theseproblems, they are then less likely to be referred on for

surgery than the more affluent. Most studies which havecontrolled for need have either failed to find anysignificant trends with socio-economic factors (Benzeval

& Judge, 1994; Haynes, 1991) or report a slightly pro-poor pattern amongst those reporting ‘‘not good’’ healthor limiting long-standing illness (O’Donnell & Propper,

1991).

Inpatient care

For inpatient care at an aggregate level, studiescontrolling for need have reported higher utilisationamongst those in unskilled manual occupations com-pared with professional groups, but no consistent trend

with occupational group was detected (Haynes, 1991).Individuals with no access to a car have been found tobe more likely to use inpatient services (Benzeval &

Judge, 1994). Analysis of GHS data using morbiditygroups (O’Donnell & Propper, 1991) and of BritishHousehold Panel data (Propper, 1998) has shown either

no significant trend with income group or a pro-poordistribution. Similarly, for children and younger people,no statistically significant differences in inpatient use arefound in relation to social class (Cooper et al., 1998).

Preventative servicesIn relation to health promotion and preventative

services, the weight of evidence suggests that lowutilisation of these services is linked to deprivation atan area level, and to poor socio-economic circumstances

at an individual level. Breast cancer is one of the fewcancers to have a higher incidence in higher socio-economic groups (as measured by deprivation scores at

area level) (Cancer Research Campaign, 1996); the trendis reversed for cervical cancer (Cancer Research


Campaign, 1994a). Most studies have found screeninguptake rates to be lower in areas with high levels of

deprivation compared with more affluent areas, mea-sured by variables such as proportion of householdswith no car, overcrowding and unemployment (Majeed,

Cook, Given-Wilson, Vecchi, & Poloniecki, 1995; Haiartet al., 1990). However, a study using individual leveldata found this association only for women living inrented accommodation compared with owner occupier

status, and even this effect disappeared in the multi-variate analysis (Sutton, Bickler, Sancho-Aldridge, &Saidi, 1994). Lower rates of cervical screening have been

found to be associated with variables such as over-crowding, Jarman UPA scores and Townsend materialdeprivation scores at an area level (Majeed et al., 1994;

Bentham, Hinton, Haynes, Lovett, & Bestwick, 1995;Eardley et al., 1985; Coulter & Baldwin, 1987) althoughthere is some evidence to suggest that the social class

gradient in screening is declining over time (Benthamet al., 1995; Cancer Research Campaign, 1994b).Similarly, rates of childhood immunisation are low inareas with high levels of deprivation (Pearson et al.,

1993a; Pearson et al., 1993b). Those in manual socialclasses are 10% less likely to attend their GP forpreventative reasons than those in non-manual groups

(McCormick et al., 1995); non-attenders at health checkclinics are more likely to be in social groups IV and Vthan I and II and more likely to be unemployed

(Griffiths, Cooke, & Toon, 1994); and attenders forchecks for cardiovascular disease are more likely to be inhigher social classes (Waller et al., 1990).

Mental health servicesResearch on the utilisation of mental health services

suggests that, in general, higher psychiatric admissionrates are associated with higher levels of deprivation atthe area level (Burglass, Duffy, & Kreitman, 1980 cited

in Cotgrove, Bell, & Katona, 1992; Hirsch, 1988; Smith,Sheldon, & Martin, 1996; Thornicroft, 1991; Giggs &Cooper, 1987; Thornicroft, Margolius, & Jones, 1992).

Studies at an individual level have usually supported thisfinding, showing a social class gradient in GP consulta-tions for mental disorders and raised rates amongst the

unemployed (McCormick et al., 1995). Other socio-demographic variables associated with higher consulta-tion rates include being single with no children, livingalone rather than cohabiting and being widowed or

separated (McCormick et al., 1995). However, given theparticular problems of defining need for mental healthservices, it is difficult to assess the whether this is a

reflection of higher need in these groups compared withthe less disadvantaged; whether a gap exists betweenhigher need and utilisation; or indeed whether those

from more affluent groups tend to use the manyalternative sources of non-NHS care available for

mental health problems but for which no utilisationdata are available.1

Long-term health careResearch in this area is beset by the difficulty of

capturing adequately the impact of the wide range ofcomplementary and substitute services outside the NHS

which are relevant to long-term care. In particular, it isdifficult (and probably inappropriate) to try to separatehealth and social care needs for most people requiring

long-term health care. In the UK this has been broughtsharply into focus by the separation of funding of publicsector social care (a local authority responsibility which

entails mean-testing of individuals) from NHS fundingof health care. It is doubtful whether any research whichdoes not take into account the full range of long-term

care provided by local authorities, the NHS, the privatesector and voluntary associations can shed light onequity of access issues.In our review we found no convincing evidence on

inequities of access to long-term health care in relationto social group, although anecdotal and prima facieevidence of inequities in some types of social care

suggests that such inequities may also exist in the healthcare sector (Bebbington & Davies, 1993; Robinson &Stalker, 1993; Audit Commission, 1996; House of

Commons Health Committee, 1996).

Interpretation

This is a complex area in which results are often

contradictory and difficult to interpret. In this section weuse the theoretical framework developed earlier toexamine what the available research can reveal about

inequity of access. Before doing so, two importantmethodological difficulties associated with the study ofutilisation patterns must be mentioned.

First, although we included only studies whichattempted to make some adjustment for differencesbetween groups in need, this is often an imperfectprocess. There is evidence to suggest that despite

attempts to control for need by categorising respondentsinto self-reported morbidity groups, those in lowerincome groups are likely to experience worse health

status, suffering a greater number and more seriousconditions than those in higher income groups(O’Donnell & Propper, 1991). If the groups are not

homogenous in terms of the level of sickness or needexperienced within each morbidity group, this suggeststhe pro-poor distribution may not exist or may indeedbe reversed.

1The scope of this review did not extend to considering the

relationship between homelessness and the use of mental health

services, although we recognise the importance of this area of

research.


Second, levels of need are often proxied by thecharacteristics of the area in which people live, rather

than by their own circumstances. Studies which haveexplored inpatient care at a less aggregate level havereported significant variations in utilisation of specific

treatments or types of care, which suggests that theaggregate level analysis may be masking some importantissues. For example, the weight of evidence relating tothe treatment of coronary heart disease suggests that

admissions, rates of investigation and revascularisationdo not match the higher levels of need experienced bythe most disadvantaged groups compared with more

affluent groups. Lower rates of angiograms and revas-cularisation in deprived areas compared with affluentareas have been reported (Black, Langham, & Petticrew,

1995; Black, Langham, Coshall, & Parker, 1996;Ben-Shlomo & Chaturvedi, 1995), whilst many studieswhich have found higher intervention rates in deprived

areas have reported that the gradients are not as steep asthey would need to be in order to match the socio-economic differential in mortality (Gatrell, Horsley,Smith, & Chapple, 1997; Payne & Saul, 1997). These

findings are supported by a study which used individuallevel data from patients reporting a history of angina orheart attack (Dong, Ben-Shlomo, Colhoun & Chaturve-

di, 1998), although another study has failed to find sucha relationship in Northern Ireland (Kee, Gaffney,Currie, & O’Reilly, 1993).

Notwithstanding these caveats, the available researchon variations in utilisation provides prima facie evidenceof the existence of inequities of access for some services.However, in order to decide how best to explore this

further, we need to identify the causes of such variations.Unfortunately, observation of realised access (treatmentreceived) is insufficient to allow us to disentangle the

causes and to distinguish between demand- and supply-side influences. We therefore discuss the findings in thecontext of the theoretical framework developed earlier.

Benefit of treatmentDifferent individuals with the same level of clinical

need may perceive they would receive very differentbenefits from treatment and thus demand may varybetween groups. However, given the nature of health

care, their perceptions will also be influenced heavily bythe supply-side as clinicians may have different propen-sities to offer treatments to patients from various socialgroups or to give different advice to such groups.

Relatively low rates of utilisation by those from lowersocial groups may therefore arise from the perceptionsof potential benefit from the clinician’s perspective

(supply) and/or the patient’s perspective (demand) andthese are not easily disentangled.Some explanations for apparent inequities of access in

secondary care services have focused on differences inrisk factors such as smoking or differences in co-

morbidities which may make clinicians consider somegroups as poor candidates for certain interventions. It is

difficult to investigate this using data at an area level,although some studies have estimated that even ifsmoking rates were twice as high in the deprived areas,

this would still explain only half the variation inrevascularisation rates between deprived and affluentareas (Payne & Saul, 1997). Other evidence supports theconclusion that such differences do not offer sufficient

explanation for observed inequities in relation tocoronary heart disease treatments (Dong et al., 1998)and prostate procedures (Emberton et al., 1995). Biases

amongst doctors may therefore be independent of need,severity or variations in risk factors and there is evidenceto suggest some GPs are more likely to refer the

economically active (and those with dependants) thanothers (Kee et al., 1995). Being economically active isalso associated with a shorter waiting time between

angiography and angioplasty (Gaffney & Kee, 1995).On the demand side, patient characteristics may

influence the stage at which they present to GPs, causinglater referrals for treatments (which in turn may make

them less good candidates for some interventions). It hasbeen suggested that those from lower social classes maybe more stoic in terms of the degree of ill health they are

prepared to put up with (Chaturvedi & Ben-Shlomo,1995) and that those who are less well educated may notappreciate the significance of some symptoms (such as

arm and chest pain) and thus may delay seeking help(Morrison, Woodward, Leslie, & Tunstall-Pedoe, 1997).Compliance rates for attendance at outpatient clinicsmay vary systematically with social group, suggesting

that even if similar rates of appointments are given,observed attendance may vary. There is some evidenceto suggest that non-attenders are more likely to be in

lower social classes (McClure, Newell, & Edwards,1996). What is not clear is the reason for non-attendancewhich may be linked to the perceived benefits of

attendance or to one of the other influences we considerlater, such as financial costs of attendance.For preventative care, health related behaviour (such

as smoking, drinking etc) and health beliefs appear to beimportant influences on the demand for care. It has beensuggested that the practice of preventative behaviours ingeneral can predict attendance for breast cancer screen-

ing (Sutton et al., 1994). If these behaviours are stronglyrelated to social class, this may explain some of thefindings reported above. A review of evidence on health-

related behaviour within socio-demographic groupssuggests that whilst smoking is more common amongstmanual groups, other behaviours such as drinking more

than a sensible amount of alcohol and eating a high fatdiet do not exhibit such straightforward patterns(Central Health Monitoring Unit, 1994). Health beliefs

in terms of perceived importance of screening may alsovary between groups (Sutton et al., 1994). Alternatively,


there may be variations on the supply side if informationon health education strategies and health promotion

services is not made as widely available to certain groupsas others. The evidence is sparse in this area.

Availability and costs of non-NHS care

The use of the private health care sector by those who

can afford it may distort observed utilisation rates wheredata are available only for NHS care. This is most likelyto occur in the secondary sector in relation to electivesurgery} some studies have shown that more than 22%

of surgical procedures for heart disease are privatelyfunded in some regions (Clinical Standards AdvisoryGroup, 1993). However, the few studies which have

taken account of this by including private sector activity(Black et al., 1996; Dong et al., 1998) still find evidenceof inequities in relation to cardiac interventions.

The wide range of potential alternatives for long-termcare (both within and outside the NHS), coupled withthe complicated payment arrangements which oftenrequire individuals to finance care in certain locations

from their own resources, means that attempts toestimate access by measuring utilisation in a singlesector are likely to give only a partial view. Demand for

a particular type of care will be heavily influenced by theavailability of alternatives and an individual’s ability topay if required. Although there is anecdotal evidence of

wide geographical disparities in the provision of sometypes of long-term health and social care (AuditCommission, 1996; House of Commons, 1996) and

concerns about discrimination against those who cannotafford to pay for long-term care (Royal Commission onLong-Term Care, 1999) there is insufficient research todraw conclusions.

There are many private and voluntary sources of carefor mental health problems which suggests that inaddressing inequalities of access it is insufficient to

investigate variations only in the utilisation of NHSmental health services. However, there is again littlegood research in this area.

Quality issues

The perceived quality of NHS care relative toalternatives will influence the decision to seek care andthe location of that care. This is likely to influencedecisions about demand for long-term health and social

care but there is a dearth of research evidence in thisarea. Decisions to seek private care for elective treat-ment may be influenced by preferences for shorter

waiting times.On the supply side, the quality of services offered to

patients with the same needs may vary systematically

with social group. Several studies summarised recently(Benzeval et al., 1995) suggest that people from the

middle classes spend more time with their GP, ask morequestions and get more information from them when

compared with those from lower social groups. Thissuggests that the latter receive a lower quality service butthe interpretation of the effect on subsequent utilisation

rates is complicated. If people from lower social groupsrequire repeat GP visits in order to receive a satisfactoryconsultation or a referral to secondary care, this mayexplain why this group has relatively high rates of GP

consultations. This may have a knock-on effect byboosting the utilisation of other services } for instancesome studies have reported higher rates of admission for

asthma (Watson, Cowen, & Lewis, 1996; Walters,Phupinyokul, & Ayres, 1995) and diabetes (Caddick etal., 1994) in areas of higher deprivation } but as some

of the admissions may potentially be avoidable, it hasbeen suggested that this may reflect inadequate manage-ment of the disease in primary care setting (Watson et

al., 1996; Caddick et al., 1994). Similar supply-side issuesat the diagnostic and referral stage may produceinequities in terms of less appropriate treatment ofother diseases also } for instance, it has been reported

that residents with cancer of the bowel, lung or breast indeprived areas of the Thames regions were more likelyto be admitted as emergency cases and less likely to

receive therapeutic or palliative surgery than those frommore affluent areas (Pollock & Vickers, 1998).

Cost to the individual of NHS care

Explanations for the variations in uptake of pre-

ventative and health promotion services have centredaround financial obstacles which, although not sufficientto stop people attending when ill, act as a barrier forusing services which may be viewed as ‘‘optional’’. Such

costs may be incurred even if the money price of care iszero as travel costs and time costs will be incurred andevidence suggests this is a possible explanation in

screening for breast cancer (Ashby, Buxton, & Gravelle,1993) and osteoporosis (Torgeson, Donaldson, & Reid,1994). In particular, women from lower social groups

attending for breast screening have been found to bemore likely to travel by public transport, be accom-panied by a companion and forgo pay or annual leave

for their time off, all of which adds to their access costs(Ashby et al., 1993).In summary, we are unable to glean much from the

literature on potential access but instead have to rely

largely on studies of realised access in which variationsin utilisation are measured. This makes it difficult toseparate the impact of supply from demand issues as the

two interact in a complex manner. The interpretation ofresearch results and the formulation of policy prescrip-tions is therefore especially particularly perilous.

Research needs to be undertaken within a clear frame-work which acknowledges the existence of a mixture of


potential influences on supply and demand for services.Qualitative methods are likely to be the most appro-

priate tools for analysis if the aim is to identify thenature of these influences and determine which are themost important in different contexts.

Conclusions

Our survey revealed a wealth of recent researchrelating to equity of access amongst socio-economicgroups. However, in the light of the theoretical frame-

work set out in Section 2, it has also highlightednumerous methodological problems that inhibit theproduction of useable research evidence and has

illustrated the difficulty of identifying the potentialcauses of inequity which may be amenable to policyinitiatives. In particular, research focuses largely on

variations in utilisation } realised access } andtherefore makes it difficult to distinguish betweendemand and supply side issues (Aday & Anderson,

1981). As a result of these problems, and the lack of aclear theoretical framework within much research isconducted, remarkably few firm conclusions can bedrawn from the extensive literature on equity of access

to health care, despite the central importance of theconcept to the principles of the NHS. Policymakers andresearchers in the USA have reached similar conclusions

even when their definitions of ‘‘access’’ appear morestraightforward (Berk & Schur, 1998; Knickman, 1998).The most important methodological difficulties are

associated with measuring and allowing for variations inneed, and the use of utilisation rates as a proxy foraccess. To some extent, the complexity of these issueshas driven research down a path where the main focus

has been on services and interventions for which thereexist readily available data and where methodologicalproblems are fewer. The result is that evidence is patchy.

It is therefore important to recognise that absence ofresearch evidence should not be interpreted as absenceof inequities. Indeed the lack of evidence may be an

indication of the existence of potentially severe inequi-ties caused by an intrinsic difficulty in monitoring thedistribution of services between population groups.

As a result of these limitations, it has been possible todraw conclusions only in a small number of areas,despite the wealth of research material. There is evidenceto suggest that levels of utilisation for some specific

inpatient procedures do not match levels of needamongst the most disadvantaged groups and a similarpicture emerges for health promotion and preventative

services. However, even where firm evidence on theexistence of inequities is available, it is still difficult insome instances to draw out policy implications. This

difficulty arises largely because of a lack of informationon the causes of inequities in access which means the

results are usually insufficiently clear to point the policy-maker in a single direction. This may in part be due to

the fact that the causes are likely to be complex andmultifaceted, rather than being attributed directly to asingle factor. Moreover, investigation of the causes of

inequities usually requires fairly in-depth qualitativeresearch which tends to be expensive and so relevantstudies tend to be small-scale. Whilst such studies mayprovide good quality evidence on one particular

potential cause, it may not mean this is the only or themost important factor which influences access.The gaps in our current state of knowledge about the

existence and causes of inequities in access to health careservices suggest that future research effort should betargeted more carefully. There is a lack of good data for

some population groups and services which are particu-larly difficult to research, but which might neverthelesssuffer serious inequities. Often research has focused on

one particular service, yet for many interventions thereexists a range of potential services which may yieldbroadly similar outcomes even though differential use isobserved. Therefore in many sectors there may be a

good case for focusing on the patients and the full rangeof potential services which may be used, rather than on anarrow intervention. Furthermore, many studies focus

on one potential cause of inequity (such as social class)and fail to take account of the full range of factors whichcould potentially influence utilisation rates between

groups (which might also embrace, say, income, housingand geography). Tackling this multivariate problemusually involves the use of large databases which allowfor the simultaneous investigation of all potential

determinants of utilisation. These methodological issueswill arise in research in any health care system and aretherefore important considerations for researchers in all

countries.Lastly, the scarcity of good quality data relating to the

effectiveness of policy interventions to reduce inequities

(NHS Centre for Reviews & Dissemination, 1995)suggests an urgent need for well-designed studies of suchinterventions which conform to the same sort of high

standards expected from clinical trials. If equity of accessreally is a high priority this research agenda should be avital part of the policy making process.

Acknowledgements

This work was in part funded by the UK Departmentof Health, through its research programme at the Centrefor Health Economics. It also formed part of the

Economic and Social Research Council health varia-tions programme, project L128251050. Thanks are dueto the journal’s referees, whose comments proved

immensely helpful when revising the paper and to HelenParkinson for excellent secretarial assistance.


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Documents

Equity of access to health care services:: Theory and evidence from the UK