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How a universal health system reduces inequalities: lessons from England
  1. Miqdad Asaria1,
  2. Shehzad Ali2,
  3. Tim Doran2,
  4. Brian Ferguson3,
  5. Robert Fleetcroft4,
  6. Maria Goddard1,
  7. Peter Goldblatt5,
  8. Mauro Laudicella6,
  9. Rosalind Raine7,
  10. Richard Cookson1
  1. 1Centre for Health Economics, University of York, York, UK
  2. 2Department of Health Sciences, University of York, York, UK
  3. 3Public Health England, York, UK
  4. 4Norwich Medical School, University of East Anglia, Norwich, UK
  5. 5Institute of Health Equity, University College London, London, UK
  6. 6School of Health Sciences, City University London, London, UK
  7. 7University College London, London, UK
  1. Correspondence to Dr Miqdad Asaria, Centre for Health Economics, University of York, York YO10 5DD, UK; miqdad.asaria{at}


Background Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period.

Methods Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare.

Results Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare.

Conclusions Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.

  • Health inequalities

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