Inequality & healthcare reform

“People with money can get friendly with their local GP at a dinner party, maybe see them out of hours if there’s an emergency” says Cameron.Paul is critical of this, and rightly so; GPs don’t want to socialize with people whose piles they saw that morning.This, though, misses the point - that there are other channels through which the middle class can get a better deal from the NHS than the poor:1. The middle class tend to be better at moaning - God knows, they get enough practice. As Julian Le Grand has written:

Insofar as complaining works at all, it favours the self-confident and articulate middle classes, thus tending to steer services in their direction. (The Other Invisible Hand, p98)

We might add to this that it’s human nature to more or less subtly sympathize more with like-minded folk, and so some doctors might give the middle class a longer hearing than poorer patients.2. Public information campaigns tend to reach the rich more than the poor, and so exacerbate health inequality.3. Doctors tend to prefer to work in “nice” areas, and so poor areas are under-provided with GPs. Back in 1971, this led Julian Tudor Hart to propose the inverse care law: “The availability of good medical care tends to vary inversely with the need for it.” Now, inequality in access to healthcare is not the main cause of health inequalities (pdf). But nevertheless it does seem to exist. One survey (pdf) in 2003 found:

There is strong evidence that lower socio-economic groups use services less in relation to need than higher ones from many studies of specific NHS services.

Equally, though, there is some evidence that this inequality has narrowed in recent years. One study found that waiting times for some non-urgent operations in 1997 were longer for poorer patients than richer ones and yet by 2007 this difference had disappeared. What’s more, this increased equality coincided with the introduction of more patient choice.Now, this is not decisive. But it is suggestive of a possibility - that competition and choice in public services, regardless of its impact on overall standards, might be egalitarian. Introducing “exit” might redress the inequality caused by “voice” alone.Which brings me to a sad fact. Debate about public service reform has crystallized along boring left-right lines. Rightists who don‘t give a toss about equality, be they Blairites or Tories, have promoted reform whilst the conservative statist left has opposed it. This, though, has led to neglect of a more interesting idea - that perhaps public services might be reformed in genuinely egalitarian directions.