20.08.2019 - Safir Şehir Portalı & Firma Rehberi Teması



the number of
established cases of a
disease in a population
at any one time.
Often described as a
percentage of the overall
population or cases per
100,000 people.
without health insurance. Here, the less well-off clearly receive poorer
healthcare. Qureshi, Thacker, Litaker et al. (2000), for example, noted that
while access to mammography screening in the USA did not vary according
to ethnicity or education level, it was lower among those with ‘healthcare
access or insurance problems’. Even among those with some form of health
insurance (Medicare), patients who live in poor neighbourhoods received
worse healthcare than those from better-off areas, particularly in rural and
non-teaching hospitals (Kahn, Pearson, Harrison et al. 1994).
By contrast, in the UK, where there is universal access to healthcare,
people in the lower socio-economic groups do access healthcare systems more
frequently than those in the higher SES groups (see Figure 2.2). At one level,
it therefore appears that there are no problems in accessing healthcare. However,
what these data do not address is whether the increased use of healthcare
resources is sufficient to counter the additional levels of poor health linked to
the lower SES groups.
What evidence there is suggests that this is not the case. In the Scottish
Executive’s (1999) report on health inequalities, for example, considerable
differences were reported between the rates of some medical and surgical
procedures between the poor and the more affluent across Scotland: rates of
hip replacements, hernia repairs and varicose vein surgery were much higher
per head of population among the better-off than those living in economically
deprived areas. In addition, although a higher percentage of the most
deprived sections of society received coronary artery bypass grafts for CHD
than did those in the higher SES groups, the relative difference was not as
great as the larger differences in the prevalence of CHD between the groups.
Although more people received surgery, the poorer population remained
relatively deprived of healthcare in comparison with those in the higher SES
These data suggest that the provision of healthcare differs according
to where you live in the UK (see in the spotlight). However, other
factors associated with social and economic deprivation may also influence
the uptake of healthcare, even when it is provided. Goyder, McNally and
a low-dose X-ray
procedure that creates
an image of the breast.
The X-ray image can be
used to identify early
stages of tumours.
coronary artery
bypass graft
surgical procedure in
which veins or arteries
from elsewhere in the
patient’s body are
grafted from the aorta
to the coronary arteries,
bypassing blockages
caused by atheroma in
the cardiac arteries and
improving the blood
supply to the heart
Figure 2.2 Health service use according to level of social deprivation in Scotland
in 1999.
Source: Scottish Executive (1999)
Botha (2000), for example, reported that attenders at a routine diabetes clinic
were more likely to be younger, to have access to a car and to have a white
collar job than people who did not attend. People with low resources may be
affected both by limited access to healthcare resources and by limited means
to access them when they are provided.
Inequalities of health provision
Health provision involves both provider and user. The ‘postcode lottery’ suggests that providers
are failing to provide equity of care across different parts of the UK, with those in the
poorest areas generally receiving less care than those in better-off areas. We have shown how
the Scottish Executive demonstrated that while more resources are available for the care of
people in more deprived areas in Scotland, these are not sufficient to cope with the serious health
needs of the population. Inequalities in the provision of service are not simply evident on a
local scale. Whole regions may differ in their health provision. An audit of the prescription
of a drug known as herceptin (see www.cancerbacup.org.uk/fund/press/RocheAudit.doc),
which can be effective in the treatment of advanced breast cancer, found that 14 percent of
women in the Midlands had access to it in 2003. This figure rose to 28 percent in the North
and North-east, 33.5 percent in the South-east and East Anglia, and 61 percent in the Southwest.
These differences were found despite herceptin being recommended for the treatment
of women with advanced breast cancer by the government’s treatment advisory body (the
National Institute for Clinical Excellence – NICE).
But it is not just at a geographical level that there are inequalities in health provision. We
show later in this chapter that differential levels of care may be provided within hospitals to
patients of different ethnic origins. African American patients, for example, may be offered
less curative surgery for CHD than white patients in some hospitals in America. People who
are poor may access healthcare less than the better-off. Finally, doctors may select patients
to have different treatments as a result of their behaviour – some high-profile doctors have
suggested, for example, that smokers should not be offered cardiac surgery as their smoking
would prevent their gaining maximum benefit from it. As economic resources become or
remain tight across all healthcare systems, inequalities in the provision of healthcare are likely
to become more frequent, and perhaps more explicit. But they only make evident what has
been the case for many years – albeit with much less publicity.
n Socio-economic status as a relative issue
So far, the discussion has considered factors that differ across socio-economic
groups that may affect health. Wilkinson (1992) suggested a further factor –
that simply knowing you are less well-off than your neighbours may in itself
contribute to ill-health. His analysis of levels of ill-health and premature mortality
both within and between countries led him to suggest that it is not just
absolute wealth that determines health: rather, it is relative wealth. He drew
on evidence that shows only a weak relationship between the absolute wealth
of a society and overall life expectancy. More important is the distribution
of wealth within a society. To illustrate his argument, Wilkinson (1990)
compared data on income distribution and life expectancy across nine
Western countries. He found that while the overall wealth of the country was
not associated with life expectancy, the variation in income distribution
across the various social groups (i.e. the size of the gap between the rich
and poor) was. The correlation between the two variables was a remarkable
0.86: the higher the income disparity across the population, the worse its
overall health.
Longitudinal data also contribute to the strength of his argument. Forwell
(1993), for example, tracked average age of mortality and income distribution
in Glasgow between 1981 and 1989, over the life of the Conservative
government. During this time, there was a significant increase in the income
distribution within the population: the income of the richer section of society
increased significantly more than that of the people in the lower SES groups.
As the differences between the income of people who lived in the poorer and
better off areas of Glasgow increased over this period, so did rates of premature
mortality among people occupying the lower socio-economic groups,
despite their access to material goods, food, clothing and so on remaining
relatively constant over time. These and similar data led Wilkinson (1992)
to suggest that for the majority of people in Western countries, health is the
result of relative rather than absolute living standards. One explanation of
these data suggests that we engage in some form of comparison of our living
conditions with others in society, and that knowledge of a relative deprivation
in some way increases risk of disease, although the mechanisms through
which this may influence health are far from understood.


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