Ensuring that access to health care is based on clinical need, not age, location, or ability to pay, is a founding principle of the NHS. But it does not necessarily follow that individuals with the same health needs but different socioeconomic status make the same use of NHS care.
In fact, after taking into account individual health needs, the highly educated aged 65 and above use considerably more NHS outpatient (specialist) care than their less educated peers. This is driven by greater use of routine and follow-up care. The gap between more- and less-educated individuals emerged only after 2010, a period of time in which the pace of NHS funding growth slowed sharply. No such gap exists for use of emergency or elective inpatient care.
These are among the findings of a new paper published today by researchers from the Institute for Fiscal Studies, University College London and London School of Hygiene and Tropical Medicine, and funded by the Health Foundation and the British Heart Foundation. The study, which exploits novel data linking detailed survey responses from the English Longitudinal Study of Ageing to NHS hospital records to examine use of NHS hospitals among the English population aged 65 years and above, also finds that:
- Individuals with more formal education (a proxy for higher socioeconomic status) are, on average, in better health than their less educated peers, and so tend to make less frequent use of NHS hospitals. 42% of those aged 65 and above with higher education report their health as ‘very good’, compared to just 23% of those with no formal qualifications.
- However, once you take actual health status into account, between 2010 and 2015 individuals with higher education made 17% more outpatient hospital visits annually relative to those with no formal qualifications.
- This education gradient in the use of outpatient care emerged only after 2010, at the same time as the pace of NHS funding growth sharply slowed. Before 2010, there were no statistically significant differences across education groups. (UK health spending grew at an average rate of 5.1% per year between 2003−04 and 2009−10, slowing to 1.1% per year between 2009−10 and 2014−15).
- These differences in use of outpatient care are mostly explained by differences in the number of routine and follow-up outpatient appointments. In contrast, there are no statistically significant differences in the number of urgent referrals, such as those following presentation of cancer symptoms, across education groups.
- There is no evidence of differences in the number of inpatient hospital admissions across education groups, after controlling for health status. This is true of both emergency and elective (pre-planned) admissions.
- There is some evidence that, after 2010, highly educated individuals used less Accident & Emergency (A&E) care than less educated individuals with similar levels of need. This could reflect reduced access to GP services, which tend to be used more heavily by those with lower levels of education, who may have turned to A&E departments instead.
- Overall, the NHS does a good job of limiting socioeconomic differences in the use of inpatient hospital services and urgent care, but inequalities have emerged in the use of outpatient (specialist) care in recent years.
Ben Zaranko, a Research Economist at the Institute for Fiscal Studies and a co-author of the study, said:
“Overall, the NHS does a good job of limiting socioeconomic differences in the use of inpatient hospital care – in line with its founding principles. However, when it comes to use of outpatient, or specialist, hospital services the highly educated are using more care than less educated individuals with similar levels of need, driven by differences in the number of routine and follow-up appointments. Further research is needed in order to understand the reasons, and consequences, of this new trend.”
Eric Brunner, professor of epidemiology at the UCL Institute of Epidemiology and Health Care and senior author of the study said:
“We show the NHS is a magnificent health care system, which continued at least until the end of the data series in 2015 to deliver elective and emergency hospital care in a socially just way to all older citizens regardless of their education level. The Covid-19 emergency has challenged the NHS. Nevertheless our study suggests the tax-funded, free-at-the point-of-use principles of the NHS provide an effective way to organise fair, universal health care funding and delivery.”