“Equal Access to all free at the point of need” But is it? Tackling inequality in healthcare.

I mentioned before that I grew up with the NHS. I remember talking to my Mum about why we had the doctor (GP) we had, and her telling me that we registered with him when I was one year old as we moved into our home. At the time, and throughout most of my life, the idea of registering with a GP retained a sort of warm 1950s glow of belonging. In my teens I discovered that you also registered to vote and that there was a list of people who had done so that could be used to canvass them at election time.

This seemed a most benign way for people to relate to government with everybody having an equal right to belong, receive services and take part in citizenship.

Much later in life I worked to try and increase the number of migrants with a GP in parts of London. Too many people were turning up at A and E who should have gone to see their GP first, but they hadn’t because they didn’t have one. So, after treatment by A and E there were GP registration forms to complete, and I began to speak at meetings about the importance of having one.

However, whenever I talked about how one acquired a GP – registration – the audience melted away. What I had seen as a form of belonging supported by a benign government – registration – was, in the experience of many refugees and asylum seekers, an echo of a relationship with a state that had been truly awful. Often they had fled their country because very bad things had happened to them and their family through the actions of the state. and now here was this man suggesting that they voluntarily go and register with the state so that it knew where they were. Not a good idea.

This had a big effect on me. Firstly, because once I ‘got it’ I was ashamed not to have got it before. It demonstrated that what had for me been the simplest cultural relationship was in fact fraught with dangers and difficulties when viewed through the prism of another cultural experience.

This of course mirrors a bigger problem. The NHS institution that I grew up with is now an organisation which enshrines a particular culture. Even the benign parts of that culture can cause problems for others and restrict the equal access that is its major principle. In the 1950s something intrinsic and normal for me – such as “registering with your GP” – had different and potentially sinister meanings for others. The NHS credo ends up meaning that we provide equal access for all providing you are comfortable with the idiosyncrasies of 1950s’ England.

Staying with the subject of GP registration, in July when I posted about homelessness, it had become obvious that the NHS only provides equal access to all if they have a home address that can be used to register with a GP. For the homeless this is difficult.

None of these basic rules were created to restrict access but roll them forward to the present day and that is what they do.

Part of the problem is a deep confusion in us all about the relationship between ‘equal’ and ‘the same’. Growing up in the monoculture of post-war England, we thought that everyone getting ‘the same’ meant that everyone was getting ‘equal’. Things would be a lot simpler if giving everyone ‘the same’ created equality, but it doesn’t. But it became clear that differences meant the ‘same’ just did not work for very large sections of the population.

In the 60s the second wave of feminism quite rightly shattered this monoculture, and the recognition of very different ethnicities also demonstrated how wrong it was.

If the NHS 2018 long-term plan, wants to move us beyond the principle of ‘equal access for all’ to its practice, we need to recognise very different cultures, experiences and genes.

Since someone with a genetic profile from Gujarat is 6 times more likely to get diabetes than a white northern European, giving them the same diabetes service is not giving them equality.

I also posted about differential smoking rates in different parts of the country. If the smoking cessation service in Surrey is the same as in Blackpool then, given their very different smoking rates, it is not equal.

Recognising the complexity of equality in an increasingly diverse society must be one of the hallmarks of the next 10 years. Or we need to stop pretending that we really believe that the principle of equal access for all can be delivered in practice