The economics of health inequality in the English National Health Service

This thesis explores the economics of health inequalities in the English National Health Service (NHS). It consists of five applied economic studies that explore different questions regarding socioeconomic inequalities and the NHS. It is bound together by an integrative chapter that provides the historical background to, and draws conclusions across, the body of work. The first of the five applied studies examined the financial costs that socioeconomic inequalities exact on the NHS, the second looked at socioeconomic inequalities in access to primary care, the third looked at socioeconomic inequalities in health outcomes attributable to the NHS, and the final two studies extended the established methods for the economic evaluation of health care programmes to explicitly value minimising socioeconomic health inequalities as well as maximising population health. These extended methods were termed distributional cost-effectiveness analysis. The studies found that dealing with the excess morbidity associated with socioeconomic inequalities cost the NHS approximately a fifth of its annual budget. Socioeconomic inequalities in access to and quality of primary care significantly improved from 2004 to 2011 in response to government policy to tackle these. However, socioeconomic inequalities in health outcomes stubbornly persisted over this period, by 2011 socioeconomic inequality was still associated with over 158 000 patients experiencing one or more preventable hospital admissions and almost 40 000 patients dying from causes amenable to health care. Distributional cost-effectiveness analysis methods were shown to be practically applicable in an NHS setting. This was demonstrated using a case study comparing population health programmes in which trading off between health maximisation and health inequality minimisation was necessary. The thesis provides an evidence base and practical new methods that should serve as a foundation to better understand the role of the NHS in tackling socioeconomic inequalities in health. In so doing, it also outlines an exciting programme of further research.