How to build a fairer health system

Clinical research should reflect the real population

For various complex reasons, White people – particularly White males – have historically been over-represented in medical research. As a result, we don’t know whether research findings represent the actual population, or if they would be different for women, minority ethnic groups or other populations who are traditionally underserved or under-represented. This means that people may miss out on timely and accurate diagnoses or treatments – even when their healthcare providers are acting on the best available scientific evidence. When people don’t receive the care they need, health inequalities are exacerbated and trust in healthcare is eroded.

Both the life sciences industry and national research regulators have recognised the importance of diversity in research and are committed to promoting it; this means involving a wider range of perspectives in the design of research studies to identify and address barriers to participation, then actively recruiting people from all populations for whom the research is relevant. In the UK, the National Institute for Health and Care Research is driving efforts to improve health equity; it requires all research funding applications to demonstrate how their research will address health inequalities. This stands in stark contrast to recent policy changes in the US, which led the FDA to remove guidance on diversity in clinical trials from its website.

What are the barriers to equitable care?

Economically disadvantaged populations are often less able or less likely to access healthcare services, and they experience worse health as a result. One study in the US found that people from low-income households who did not have health insurance were around 2.5 times more likely to visit an emergency department for a problem that could have been prevented if they had been seen earlier. In the UK, where health insurance is not needed, people in the most deprived 20% of the population are almost twice as likely as the rest of the population to use emergency services. This demonstrates that inability to pay is not the only barrier to timely access; other challenges – including difficulty travelling to appointments, inadequate provision of services in deprived areas, previous experiences of discrimination, language barriers and mistrust – also make people less likely to seek care.

Ensuring equitable access to healthcare is not a simple proposition. It requires system-wide change. However, providing services in central locations or via mobile units can help. For example, rapid cardiorespiratory screening delivered at a football club in an underserved area of the UK diagnosed almost 1 in 3 people with high blood pressure; many of them required emergency care. Mobile screening units in many countries have also helped detect lung cancer earlier, including among people from underserved populations who otherwise may not have been diagnosed until much later.

How can health systems build trust?

Even when research organisations or healthcare providers implement outreach strategies that aim to include traditionally under-represented groups, people may choose not to engage because they don’t trust the system. This mistrust has roots in historic injustices – most infamously the Tuskegee Syphilis Study – but also in individuals’ personal experiences of discrimination in the health system (which has been identified as an important factor driving a lack of trust in the NHS) and inequalities in healthcare usage and outcomes during the COVID-19 pandemic.

There are many ways to build trust and address discrimination; my colleagues at HPP have written a fantastic report on the topic. One important component is to commit to diversity and inclusion in the workforce. While evidence shows that patients tend to prefer healthcare professionals with whom they have something in common – such as sex, gender or culture – the healthcare workforce in many countries is not representative of the wider population. This gap could be narrowed through targeted strategies, such as matching healthcare workers and allied health professionals, including community health workers, with the populations they serve.

Health equity benefits everyone

There are many ways in which we can work to reduce health inequalities, and meaningful progress will require targeted strategies to improve diversity and inclusion across the health system. These strategies are not part of a particular political agenda, but a fundamental component of ensuring that all people get the care they need, when they need it, to prevent ill health and support the wellbeing of the whole population.

The opinions expressed in this blog are those of the author and do not necessarily represent the views of The Health Policy Partnership.