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Views And Reviews Taking Stock

Rammya Mathew: Reshaping healthcare for vulnerable people

BMJ 2020; 371 doi: (Published 17 November 2020) Cite this as: BMJ 2020;371:m4426

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  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

The covid-19 pandemic continues to rip through the global population, disproportionately affecting ethnic minorities and lower socioeconomic groups. It has brought the need to tackle health inequalities into sharp focus.

The Inequalities in Health Alliance—a new coalition of health and social care organisations in the UK—is calling on Boris Johnson, the UK prime minister, to implement a cross government strategy to tackle the many complex and interwoven factors that feed into health inequalities.1 Evidence shows that dealing with the social determinants of health would have by far the greatest impact2; however, I worry that, by attributing the entire “health gap” to these social determinants, we’ve cultivated a sense of apathy among healthcare leaders and policy makers when it comes to tackling underlying problems within the healthcare system itself.

Look at primary care alone, where 90% of patient contacts happen, and some stark data highlight this inaction. General practices serving more deprived populations receive 7% less funding than those serving more affluent populations, once we consider the increased workload associated with greater health need.3 The Carr Hill formula is designed to adjust core funding for general practice, in line with a number of local demographic factors—but why has this not been revisited, when we have clear evidence that it’s not doing enough to level the playing field?

Deprived areas also have fewer GPs per head of population when adjusted for need, and those GPs are responsible for the equivalent of 10% more patients than doctors working in more affluent areas.3 Yet, in the past decade, the only substantial effort to increase GP supply in under-doctored areas has been in the form of paltry, time limited financial incentives,4 which we know are unlikely to achieve the desired long term impact.5

Then consider the Quality and Outcomes Framework, a system designed to remunerate GPs for providing high quality care for their patients. In setting the threshold for maximal financial achievement at 80-90% of the target population having the desired intervention (be that a blood pressure check or a cardiovascular risk assessment), we find a situation whereby the same “hard to reach” groups get overlooked year on year. It’s an example of how a well intentioned policy, designed to improve care, becomes yet another source of inequality that we’ve created ourselves within healthcare.

As a profession we have a role in campaigning for social justice, and I welcome the call for the government to look at health inequalities with the wide lens this deserves. But if we wait for the dawn of an equal society, where poverty and injustice cease to exist, we’ll miss valuable opportunities to prioritise the needs of the most vulnerable people when reviewing the fundamentals of healthcare policy and delivery.


  • Competing interests: I co-lead Islington GP Federation’s Quality Improvement Team.

  • Provenance and peer review: Commissioned; not externally peer reviewed.