Intended for healthcare professionals

Education And Debate

Equity issues in the NHS: Who cares about equity in the NHS?

BMJ 1994; 308 doi: (Published 14 May 1994) Cite this as: BMJ 1994;308:1284
  1. M Whitehead
  1. The Old School, Ash Magna, Whitchurch, Shropshire SY13 4DR.
  • Accepted 24 April 1994

The concept of equity in relation to the National Health Service in Britain encompasses not one but at least eight distinct principles. Until the 1980s the NHS had a good record of incorporating these principles into practice. Throughout the 1980s, however, there has been a pronounced change, with the gradual introduction of business values into the service, culminating in the market based reforms of the 1990s. Several recent policies seem to be taking the NHS away from the goal of an equitable system - for example, the new arrangements for community care and the incentives within contracting to select patients on financial grounds. To restore equity as a value demands priority for ethical values, monitoring of policies for their effects on equity, some national planning, and a new debate about the entitlement to services such as continuing care.

Over the past decade successive reorganisations of the NHS have been presented as technical adjustments, to improve efficiency, quality, and patient choice but without affecting the basic equitable foundations of the service. The impression is of noble intentions, but if we dig beneath the rhetoric is the principle of equity being upheld and protected, or is it being quietly abandoned?

Why the NHS was established

In the midst of continual reorganisation it is easy to forget why the NHS was set up in the first place. The political consensus for change grew out of a widespread realisation that the prewar system was inequitable, inefficient, and near to financial collapse.1,2 In the 1930s, for instance, only 43% of the population were covered by the national insurance scheme, mainly men in manual and low paid occupations and only for general practitioner services.1 That left 21 million people, predominantly the wives and children of employed men, not covered by the scheme. The sick carried much of the burden …

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