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Background
The concept of equity - or fairness - is central to the organisation
of most systems of health care. In particular, the National Health
Service gives the pursuit of equity a central role. There is a widespread
belief that if equity objectives are ignored the NHS will lose the
widespread support of citizens that is necessary for any service
funded out of general taxation.
One important
equity objective is the reduction of inequalities in health, the
existence of which has been well-documented. But how averse is the
general public to these inequalities? Does the cause of the inequality
make any difference to the attitudes of the general public towards
them? Should ill-health caused by lifestyle be afforded the same
health care priority as ill-health beyond the control of the individual?
To what extent should equity objectives be weighted in relation
to efficiency considerations when setting priorities for reducing
variations in health?
Aims and
Objectives
In spite of the central role of equity considerations within the
NHS, there exists surprisingly little analysis of the concept, let
alone relevant empirical evidence. The purpose of this research
is to move towards correcting this lacuna. The objectives of the
research are to:
- identify
what ordinary citizens interpret as 'fairness' in relation to
health and health care;
- examine the
relative importance placed by citizens on different forms of equity,
and the extent to which they are prepared to trade off efficiency
against equity in the distribution of health care resources;
- present the
results in a form which helps policy makers determine the weight
to place on equity considerations vis-a-vis concerns for efficiency
when designing policies to address inequalities in health;
- furnish health
authorities and other policy makers with the means to ask citizens
meaningful questions in relation to equity.
Study Design
The study is organised in five stages. Concepts of equity will be
examined, and methods developed to explore the views of the public
in relation to these concepts. We will first seek the views of 36
citizens through a set of one-to-one semi-structured interviews
and focus groups. The study team will then use the findings to develop
more formal preference elicitation instruments, in the form of one-to-one
interviews with about 150 citizens, and a postal survey of a representative
sample of 2,000 individuals. Both quantitative and qualitative methods
will be used to analyse the data from this stage. The study will
identify the most important themes concerning equity which emerge
and disseminate the results to both academic and policy audiences.
The intention is to recommend to policy makers how they might formulate
more focused equity objectives than hitherto.
Policy Implications
To date, most health care policies have been framed on the basis
of efficiency criteria. This study is pioneering in the sense that
it is seeking to develop an operationally useful approach towards
incorporating equity considerations into policy decisions at both
a national and a local level.
In doing so,
it will shift the focus of discussion from the "expert opinions"
of ethicists and philosophers to public opinion about fairness in
the NHS. It will also enable the body of research evidence to move
on from investigating the existence and correlates of health inequalities,
and proceed to the systematic investigation of the relative importance
attached to them by the general public.
By developing a more reliable means of eliciting public preferences
about fairness and by generating empirical data of a kind that have
not previously existed, we shall:
- offer policy
makers better methods for eliciting the views of their own populations
(and comparative data on how they compare with our study sample);
- provide empirical
data which can be used in priority-setting and thereby ensure
that equity objectives get their due weight alongside efficiency
objectives.
Project Summary
The NHS aims to allocate resources for health care on the basis
of securing equal opportunity of access for equal need. This principle
is now under review, with ministers seeking to ensure that the allocation
formula includes an element which contributes to reducing avoidable
health inequalities. However, targeting resources at reducing health
inequalities may mean diverting resources from other potentially
beneficial activities and may only be achievable at the expense
of some reduction in the total health improvement achieved by the
NHS.
Little is known
about public perceptions of health inequalities and their targeting
through the allocation of NHS resources. This project begins to
address this gap in the evidence-base of health policy. The study
explored how the public views the concept of health equity and the
extent to which people are prepared to sacrifice the maximization
of health gain in order to secure some reduction in health inequalities.
It sought the views of citizens through a series of focus groups
and semi-structured interviews (n=33), a set of one-to-one interviews
(n=130) and a postal questionnaire (n=833). In addition, a parallel
national survey has been undertaken in Spain (n = 1,200).
Key findings
- In the focus
groups and semi-structured interviews, information on health inequalities
was familiar to the majority. However, respondents expressed surprise
at the magnitude of the differences in health between the social
classes. The concept of fairness was well-understood, enabling
a more formal means of eliciting preferences to be developed.
- Evidence
from the focus groups and semi-structured interviews indicate
that people are willing to give differential priority to groups
with different characteristics (such as age, family responsibilities
and the extent to which people are 'responsible' for their illness).
- Evidence
from the interview-based and postal questionnaires demonstrate
that citizens can make meaningful responses to questions about
equity and can indicate the relative strength of their preferences
for reducing different kinds of health equity. These preferences,
and their associated trade-offs, can be measured and quantified.
- Evidence
from the interviews and postal survey indicate that the majority
of people are willing to target considerable NHS resources at
the reduction of health inequalities.
- The variation
in public views is nevertheless considerable. For any given health
inequality, at least 40% of the population is not persuaded that
traditional NHS activity should be sacrificed in order to address
the inequality.
- Willingness
to tackle a health inequality varies depending on how it is described.
For example, a majority of respondents are unwilling to target
NHS resources at an inequality defined by smoking status or gender.
This suggests that the general public's response to health inequality
policy may be highly dependent on how the policy is presented.
- In the interviews
and postal survey, there were no significant differences in attitudes
to tackling health inequalities across different socio-economic
groups or between men and women. For example, those with educational
qualifications were no less willing to see health care resources
targeted at social class V than those without qualifications,
and women were no less willing to extend the lives of men than
were men themselves.
- The study
has resulted in the development of a new research instrument to
measure perceptions of equity. This instrument enables people
to indicate their strength of preference for different forms of
reduction in health inequalities (e.g. average life expectancy
at birth and limiting long-term illness), across different population
groups (i.e. socio-economic status, sex and smoking status). The
instrument, used successfully in the interviews and postal questionnaire,
provides an important resource for policy makers in the UK. It
also has scope for use in other countries (the project team has
established contacts with Denmark, Northern Ireland, Spain, Sweden,
and the US).
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