nf0262: okay welcome to week six of health in the community [2.8] just for 
reference er week six is outlined or the morning sessions are outlined on page 
twenty-one of your handbooks [5.2] so as you all remember we've got a whole 
day's session in the university [0.3] today [1.6] before we [0.3] begin this 
morning er [2.3] this lecture and all the lectures this morning are being 
filmed for [1.7] a research project [0.2] er [2.0] the aim [0.4] of the lecture 
is is really to [0.9] to video me [0.7] but namex also wants to have a camera 
on the audience as well [0.5] so she's just going to come and explain about the 
[0.3] research project and then seek your permission [0.4] to film you as an 
audience [laughter] so [4.9] 
of0263: is this working [0.9] hello everyone [0.3] can you hear me [0.8] 
sm0264: shh [0.3] 
of0263: er hi my name's namex and i'm a research assistant at the Centre for 
English Language Teacher Education [0.3] CELTE [0.4] and er this filming is 
being carried out as part of a [0.2] part of two research 
projects actually on [0.4] academic spoken English [0.5] so er we'd just like 
to have your permission just to make sure that nobody objects strenuously to 
being filmed [0.6] is is that okay with you [1.6] any objections [laughter] [0.
9] [laughter] [2.4] all right thanks very much [2.2] 
nf0262: thanks [2.2] well the only advantage from my point of view is that i'll 
have on camera those of you that have fell as-, fallen asleep [1.0] [laughter] 
okay [0.5] so let's er [0.3] let's set off [0.6] okay [0.2] so the timetable 
for this morning it's quite a heavy timetable this morning we're going to start 
off by [0.5] er having er a a a a [0.2] short thirty minute lecture on 
inequalities in access to care [0.6] then after probably just a two minute 
stretch [0.4] and er [0.2] ti-, a comfort stop we'll then [0.2] follow it by 
another thirty minutes looking at how inequalities can be tackled [0.9] then 
we've got a coffee break [0.2] and then we'll finish off the morning looking er 
further at the theme of tackling inequalities in health [0.4] and looking at [0.
3] the 
policies and initiatives that have been put in place [0.4] to tackle health 
inqualities [1.7] are there any questions about that before we start [1.3] so 
the learning outcomes of this morning's session are outlined on [0.3] page 
twenty-one [1.8] so we're beginning then by looking at inequalities in health 
care [1.3] what i should say is because of the difficulties of accessing [0.3] 
the Powerpoint slides on the learning environment which seems to be a 
continuing problem [0.7] er the slides for [0.2] all of today's lectures will 
be [0.2] photocopied [0.3] and put in your pigeonholes [0.3] because i'm aware 
that you need er the slides from today's session [0.4] to help you to write 
your formative assignment which is due in on Friday [0.5] so that's also a 
reminder t-, that your first formative assignment your essay plan [0.3] i-, [0.
3] is to be handed in by four o'clock on Friday [1.6] okay but let's begin then 
by talking about inequalities in health care [3.8] so to [0.6] first of all i 
just want you to think about what we mean by the terms [0.2] equality [0.2] and 
equity [4.2] 
we've been looking at [0.9] over er a period of weeks [1.3] the fact that [0.2] 
there is substantial evidence that documents that we have wide [0.4] 
inequalities in health in in terms of inequalities in health status and health 
experience [0.3] between different social groups [2.9] but the evidence 
suggests that lack of access to health care [1.1] only makes a minor 
contribution [0.3] to the overall difference in mortality and morbidity [3.1] 
but having said that [0.8] it's also widely acknowledged that health services 
do have an important role to play [0.5] in ameliorating and helping people cope 
with [0.3] the damage to their health caused by poor material [0.3] and social 
conditions [0.4] so having said that lack of access or unequal access to health 
care [0.4] isn't the cause of health inequalities [0.3] that's not to say that 
they aren't an important issue [4.9] but we need to bear in mind that [0.5] 
equitable [0.2] health care provision [1.0] er [2.4] is important [0.6] rather 
than equality in health care provision [0.5] so if we're talking about er [0.7] 
providing people with 
access to care then we need to make sure [0.2] thak ik that it's equitable 
according to need [0.5] rather than er [1.5] having it distributed equally [0.
6] amongst the population [6.7] an equity of access to health care is a central 
objective [0.4] of the U-K National Health Service and it has been since its 
inception [0.3] in the mid-nineteen-forties [2.5] there's strong evidence that 
those in [0.2] poor material and social circumstances [0.2] low income groups 
[0.4] er are li-, er in particular are likely to experience [0.5] the w-, 
poorest health status [0.5] suffer [0.2] er a greater number of and more 
serious conditions [0.3] than those in better social and material circumstances 
we've been looking at that evidence [0.2] and it's been very clear [2.2] so 
this suggests then [0.2] that er those in low income groups those in the 
poorest social and material conditions [0.6] need would need to use health care 
services more than those who are better off [2.9] so a key question that we 
need to examine and try to answer [0.3] is do those with the greatest health 
care needs [0.3] have [0.5] equitable access 
to health care services do they have access [0.4] er [0.2] er to to services 
according to their needs [4.9] so a large number [0.2] of research studies have 
looked at this question [0.8] and they have documented that there are 
inequities in access to health care [1.6] but when we look at the evidence it 
shows quite a complex picture [1.5] these studies show that in many areas and i 
mean both areas in terms of geographical areas as well as areas of service [0.
5] those with the greatest health needs er do have er poorer access to health 
care [0.4] er than those who are better off [0.2] and this was identified very 
clearly in nineteen-seventy-one by Julian Tudor Hart [0.4] who identified that 
an inverse care law applies [0.3] er to Britain [0.8] and Tudor Hart said that 
the availability of good medical care [0.4] tends to vary inversely with the 
need for it in the population served [1.9] and the empirical evidence for this 
law has accumulated steadily over time [1.2] but as i said [0.5] the evidence 
is quite [0.2] is complex and er [1.0] there is evidence for 
inequities in health care in some areas but not in others but we're going to 
start off by looking at some of that [4.0] so what [0.2] the evidence shows us 
overall is that there are inequities in access to some services not all 
services [2.4] and there's inequity in access to facilities and [0.2] to 
treatment and care [5.2] there are also inequities in the utilization of some 
services [1.4] so the way that services are used whether they're underused and 
overused [2.6] and there are also inequities in the availability of responsive 
services [1.0] because it's it's important not only to have services that are 
there for people [0.4] but for people with er substantial health care needs 
it's important to have services [0.4] that er [0.2] that they feel able to use 
[0.4] that are accessible [0.3] but also that are responsive in terms of 
targeted to addressing [0.3] and meeting those [0.3] their particular health 
needs in a form that are acceptable to them [0.7] and that's an issue we'll be 
going to be talking much more about this afternoon when we look 
at woi-, working with [0.3] disadvantaged er [0.5] er [0.9] patients and 
disadvantaged communities [3.6] but let's [0.2] first of all look at 
inequalities in access to primary health care [0.6] and what we're going to see 
is a bit of a mixed bag [4.6] the reviews er of r-, of that have looked at er 
[0.4] the breadth of research in d-, i-, [0.2] in in er [0.6] access to primary 
care [0.5] suggest that there probably now is a pro poor bias in G-P 
consultations and that's to ex-, [0.3] to some extent what [0.3] what you would 
expect [0.9] there are higher consultation rates er [0.2] for those people who 
are ill amongst disadvantaged groups [2.5] and that this occurs even when need 
is controlled for [2.5] but there is still continuing evidence that [0.7] some 
[0.2] marginalized groups have difficulty er accessing primary health care [1.
1] in particular if you think about it the kinds of groups that have difficulty 
in accessing primary health care [0.3] are groups like asylum seekers [0.7] er 
[0.7] people who are homeless [0.6] er who because they don't have er a place 
of residence [0.3] may 
find it ax-, er difficult to get on to G-P lists [0.8] travellers [0.4] er s-, 
many er G-Ps are er [0.9] don't register travelling families [0.4] and and as 
tr-, families are travelling round they often find when they [0.3] they settle 
for a short period it's difficult t-, to get access to G-P services in 
particular areas [3.4] some [0.3] trusts and er [0.2] and groups of G-Ps er 
have come together to provide specialized health services for these groups [0.
3] to try and er [1.0] get round the difficult issue that some of these groups 
may have [0.3] in terms of registering with a G-P [0.4] so for example [0.4] 
Coventry er [0.6] i-, in Coventry tr-, [0.2] Coventry Primary Health Care Trust 
has a particular [0.2] er [0.5] er specialist service to provide health care to 
asylum seekers and refugees [4.2] but there's also evidence of inequitable 
access to particular services [0.4] so for example there's some evidence that 
er [1.1] there are inequities in access to health visiting services for people 
in disadvantaged groups [0.5] and Reading and Allen in nineteen-ni ninety-seven 
looked at access er for 
those with the poorest health needs to health [0.2] health visiting services [0.
5] and although they found that [0.2] some account had been taken of the fact 
that [0.3] er those in er living in disadvantaged areas had greater health 
needs and there had been some attempt [0.5] to er provide extra health visiting 
services in those areas [0.4] the additional er resources that had been put in 
were nowhere near [0.3] adequate enough to meet the substantial needs [0.4] er 
and [0.3] er health needs er and care needs of those families in those areas so 
although there were additional health visitors [0.3] there weren't enough 
health visitors to meet [0.3] the service requirement [3.8] there's also 
evidence of underutilization of preventive services in primary care [1.5] so 
there's a er people like McCormick er Majeed and Goddard and Smith [0.5] have 
looked at the utilization of services in primary care [0.3] and show and and 
their work suggests that manual social groups are less likely to attend their G-
P practice [0.3] for preventative care [0.5] so although we've 
got [0.4] er high cons-, consultation rates when people are ill when it comes 
to [0.3] attending for preventive health care [0.3] then [0.2] uptake er is 
much much lower [2.3] and also er [1.6] there's [0.7] also evidence of uptake 
of poor uptake for things like er screening services and particular preventive 
care like immunization rates [1.1] child health screening and cervical 
screening [4.7] let's [0.9] move from primary care then to look at secondary 
care and what happens when we look at access to secondary care [2.1] well [2.8] 
the studies that have looked at access to secondary care [0.5] suggest that er 
the systematic reviews that have been done suggest that there's no evidence of 
inequities in [0.3] the total number of referrals [0.2] or referrals for [0.2] 
for medical conditions that are made [0.4] er [0.2] er [0.4] to clinicians in 
secondary care [0.5] so [0.4] that's when clinical need is controlled for [1.0] 
so the total number of of referrals [0.3] and referrals com-, er medical [0.4] 
conditions seem to be according to need [2.3] but when you look at er referrals 
for some specific 
conditions ref-, requiring surgery [0.4] then there's some strong evidence that 
those with the greatest needs have the poorest access [0.8] and Chaturvedi and 
bensh-, Ben-Shlomo's s-, study [0.2] er [0.3] they've looked at several areas 
of access to care [0.5] er they've looked at er access and surgery for 
arthritis of the hip and their work showed [0.4] that er [0.3] if you were 
disadvantaged [0.4] er then you were less likely to be referred for surgery [0.
3] th-, er er [0.7] f-, for [0.3] hip surgery than those who were better off [1.
5] regardless of need [3.6] there als-, also evidence for inequalities in 
access to inpatient treatment [1.6] and again there's a number of studies that 
have documented this [1.4] disadvantaged patients are less likely to be 
investigated er with [0.2] er using coro-, coronary angiography [0.5] and less 
likely to be referred for coronary artery bypass grafts [0.2] than those who 
live in more advantaged area [0.5] and again this is quite well documented in 
research by Ben-Shlomo [0.4] and Chaturvedi [0.2] in nineteen-ninety-five and 
Payne and 
Saul in nineteen-ninety-seven [2.1] there's also evidence that er [0.5] 
patients from disadvantaged areas [0.3] wait longer for cardiac surgery once 
they have been referred and once they have been identified as having a clinical 
need [0.5] er than those who were better off and this is because they're less 
likely [0.3] to have their operations er identified [0.3] classified as of 
urgent priority [0.4] and the wait was something like three or four weeks 
longer [3.5] so we've documented [0.2] er [0.5] a complex pattern of 
inequalities in access to [0.2] to care both in primary care [0.3] and to 
secondary care [2.2] so how do we explain [0.2] inequalities in health care [2.
3] well again [0.5] the reasons for er [0.4] inequities in health care again 
quite complex and muls-, multifaceted [4.5] there's little doubt that those who 
are disad-, materially and socially disadvantaged [0.4] er ec-, experience 
particular barriers to seeking and receiving health care [0.5] and these 
barriers are both financial [0.7] geographical [0.4] social [0.4] and cultural 
barriers [4.4] and these we-, [0.3] this afternoon we're going 
to look at er these barriers in much more detail and look at some of the ways 
that these barriers to [0.4] er seeking and receiving health care [0.4] can [0.
2] be reduced for those who have the greatest health care needs so i'm not 
going to say any more about those things now [4.4] another possible reason is 
the attitudes of health care workers [0.5] certainly research that has looked 
at the attitudes of a of a number of of groups mainly health visitors [0.2] er 
social workers [0.3] er health promotion workers [0.4] er has suggests suggests 
[0.2] that [0.3] there are particular views about er [1.2] those with the 
greatest needs those in the poorest conditions that are held by health workers 
which may mean they're not offering [0.3] the kinds of services and the level 
of services that those people need [1.0] er there are notions that er of 
undeserving poor not all groups in in in [0.5] er [0.6] socia-, poor social 
material conditions are viewed in the same way [0.3] some groups are seen as 
more deserving than others [1.0] you can probably can anybody think 
of those any groups that might be seen as particularly undeserving [2.9] 
ss: [0.5] 
nf0262: hear some mutterings [1.9] 
sm0267: smokers [0.2] 
nf0262: smokers might be one can you think of any more [0.7] 
sf0265: drug dealers [0.4] 
nf0262: pardon [0.5] drug dealers yeah [0.2] yeah [3.7] 
sf0266: prisoners [0.4] 
nf0262: pardon [0.6] 
sf0266: prisoners 
nf0262: prisoners yeah [0.2] maybe maybe some asylum seekers [0.4] er [0.2] 
those particular groups who don't behave in the way that er we might think they 
should behave [0.4] er [0.7] there's also possibly negative stereotypes for 
particular minority ethnic groups [0.4] groups that are li-, more likely to be 
seen as deserving maybe groups like mothers with young children [0.3] but there 
there er [0.2] it's proba-, probable that the attitudes of health care workers 
[0.3] er and the way that they perceive particular groups of patients [0.4] er 
may mean that they don't offer services or the or appropriate services to 
specific groups of disadvantaged families [4.7] also [0.6] er an explanation is 
likely to be related to the 
knowledge of health care workers [1.1] first of all that workers may including 
[0.2] doctors may [0.8] fail to recognize or understand the health needs of 
disadvantaged groups why has it done that hang on [0.6] let's go back there we 
go [0.9] er [2.5] because of knowl-, because of lack of knowledge that their 
their health needs n-, may be greater [0.5] or n-, n-, knowledge and lack of 
understanding about their how their health care knowledge can be addressed and 
of course [0.4] a key er learning outcome for this module [0.4] is that both er 
[0.2] both from your university based teaching and your [0.2] your community 
based teaching [0.4] is that you will develop a body of knowledge [0.3] which 
will enable you to recognize and understand [0.3] the health needs of those who 
have the greatest health needs in our society [1.5] so it's fairly to recognize 
or or understand health needs but also lack of knowledge about how to address 
[0.2] the specific health needs [0.4] er through the development of responsive 
services [0.4] 
and again this afternoon we're going to look at [0.3] er those issues in much 
more detail [1.6] er [2.3] an example of er [1.3] this i-, of of [0.3] of 
practitioners in a er failure to address specific health needs through the 
development of responsive services [0.5] was thrown up by this study [0.2] er 
which by is Feder et al in in two-thousand-and-two [0.5] which looked at and 
it's this is er in the British Medical Journal where you'll find [0.4] lots and 
lots of articles on inequalities and inequities in access to care so that's a 
very good [0.4] place to go if you put in the terms i-, er [0.3] inequality in 
access to care you'll throw up thousands and thousands of references [1.2] but 
this study looked at er [1.5] tried to identify er [1.0] why there were lower 
coronary o-, [0.2] or looked at coronary revasculize revascu-, [0.9] 
revascularization [0.2] for er [0.9] different groups of patients [0.6] so by 
revascularization we mean access to angioplasty and to coronary art-, coronary 
artery bypass grafts and this study showed [0.4] that er [1.1] people of South 
Asian origin had [0.8] 
lower [0.9] er [1.2] rates of [0.2] of er angiopasty and coronary artery bypass 
grafts [0.4] than white patients [0.3] but this didn't appear to be explained 
by [0.2] physician bias because [0.4] the study er [0.4] look-, asked groups of 
physicians [0.2] to [0.3] identify er [0.2] groups of patients from the notes 
er without showing people's ethnic stat-, without showing the patient's ethnic 
status [0.4] to [0.5] from the clinical data to decide whether particular 
patients [0.3] needed revascularization [0.7] er so this wasn't explained by 
physician bias [0.4] but may be explained but they were suggesting er m-, [0.7] 
that [1.6] it the lower rates were ex-, [0.8] explained by the fact that [0.3] 
South Asian [0.2] patients were less likely to [0.2] er go on to be [0.5] to 
have angio-, angioplasties or coronary artery 
bypass grafts [0.4] possibly because of the culture and language barriers [0.3] 
and that physicians [0.3] that they they felt were there and that the 
physicians needed to find a way of [0.4] er reducing these barriers so that [0.
2] patients this particular group of patients [0.4] er would understand the 
need for [0.3] and feel more able to er receive the [0.3] er the kind of of er 
surgical procedures [0.3] that er was being idenif-, identified as as as as 
clinically important for them [2.5] okay [0.8] we're going to have a two minute 
break now [0.3] er before we look at how inequalities can be tackled [0.3] so 
we'll just have a two minute stretch and comfort break