Today I had an article published in the British Medical Journal, along with an accompanying editorial[1] and a front page press release (which will be visible for about 3 minutes before the next health care fad overwhelms it). The article itself is an investigation of rates of referral to secondary care (that’s “hospital” to the non-initiated) by General Practitioners (“Doctors” to the non-initiated), which uses GP routine monitoring data to estimate the difference in rates of referral for key conditions by socioeconomic status, age and sex. The key finding is that poorer people tend to be referred less frequently or at longer time intervals than wealthier people, as do the very old, except where strict guidelines exist that restrict GP choice. The implication, of course, is that something happens in the GP consultation that disadvantages poorer or older people.

The research was conducted in conjunction with a Public Health Trainee and two other academic departments while I was working at the King’s Fund, in London. The statistics are, in my opinion, pretty robust, and the findings pretty stark, and the diseases we considered are interesting for their implications. We looked at referral rates for three conditions:

  • Post Menopausal Bleeding, which is a symptom of serious health conditions and should always be referred to further care
  • Dyspepsia, which is a symptom of illness in people over 55, and for which referral guidelines exist in this age group
  • Hip Pain, which by contrast is generally considered an indicator of osteoarthritis and which has no clear guidelines or medical opinion on what level of referral should be provided

Our hypothesis was that the existence of guidelines would eliminate referral rate discrepancies (in the case of dyspepsia) and that the vague nature of hip pain science would mean that referral rates would be dependent upon the GP-patient interaction. Our hypothesis got strong statistical confirmation from a very robust dataset. The accompanying editorial attempts to present a theory of how this might occur, because it’s not immediately obvious why. Noone who wrote this paper thinks that GPs are sitting behind their desk concluding that poor people don’t deserve care, and the data don’t tell us why the discrepancy exists. Note that in the case of hip pain the available knowledge is such that we don’t even know what the right referral rate is.

My personal theory (not necessarily shared by my co-authors, who are quite capable of speaking for themselves) is that poorer patients are less capable of  representing their interests to a better educated and highly respected, wealthy doctor. They don’t express the need for pain relief or advanced care, and they don’t advocate for their own needs. I think there may also be an internalized social view, held by many poor people (deferential toryism) and some doctors that poor people don’t deserve the same quality of life as wealthy people, and should be thankful for what they’ve got. This means that everyone involved in the consultation is not advocating for or not offering the service that should be available. Of course this only happens in some consultations and it happens subtly – it’s not like anyone is thinking “you’re poor, just go home and die already!” or even that the doctor is thinking anything less than that they should provide the best service they can. But there are different cultural expectations of health in different classes, and they create subtle barriers to the best quality of care amongst poor people. I think this is an important example of how culture is as important as simple structural or economic issues in setting the determinants of health inequality.

Other theories, of course, are welcome. This is hardly settled science, and my job is to do the calculations, not to explain them!

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fn1: incidentally, these articles require you register to read them fully. It’s probably not worth your time…