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