Thinking about equity in health care

Public health care systems such as the British National Health Service typically profess two principal objectives: to improve the health of the whole population; and to reduce inequalities in health within it. Given scarce resources, these objectives are often in conflict. Much attention has justifiably been paid, by health economists, to addressing the former objective with methods of economic appraisal. My intention is to focus on the more difficult issue of the pursuit of ‘equity’ in health care, specifically the desire to reduce inequalities in health. This raises philosophical and policy questions about what makes some people more deserving of care than others, and whether or not society should adopt a forgiving stance towards those who have compromised their health status in some way, and offer access to treatment. Also, decision‐makers may need to distinguish between the goal of raising the level of those worse‐off and reducing inequality across society as a whole. Moreover, it is important to clarify what we wish to be made less unequal within the realm of health care provision. Tough decisions like these are based on value judgements and trading off one priority against another. In the interests of equity, such decisions need to be transparent and based on the preferences of society as a whole rather than covert and capricious. No manager needs reminding that resources are limited or that if more favourable treatment is accorded to some, inevitably less favourable treatment is accorded to others. Policy‐making for a whole unit requires a nurse manager to offer a perspective on multidisciplinary matters and engage in wider public policy issues facing the team. As circumstances change, existing practice may be challenged as unfair, inefficient, or failing to account for important patient characteristics which make them different. Here, thinking clearly about equity is very important, and nurse managers are important as clarifiers of the thinking about what should be considered when making these difficult decisions.