BMJ 2017;358:j3653 doi: 10.1136/bmj.j3653 (Published 2017 July 28)

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Letters

LETTERS SURGE IN EXCEPTIONAL FUNDING REQUESTS

Access to care is not equal S Michael Crawford clinical lead for research Airedale NHS Foundation Trust, Keighley BD20 6TD, UK

When more patients than previously are being denied access to care and some of them are consequently initiating exceptional or individual funding requests,1 2 the question of fairness arises. We already know that access to joint replacements is lower in deprived areas.3 Perhaps patients from the articulate and assertive end of the social spectrum are more likely to ask their GPs to pursue an individual funding request. Socioeconomic status is known to determine health, but its effect on uptake of healthcare is rarely highlighted. Michael Marmot, in his book The Health Gap, says that survival of poorer patients with cancer after treatment is inferior, but he discounts the possibility that this might be related to access.4 Evidence indicates that residents of poorer neighbourhoods have reduced access, which is exacerbated by distance from services.5 A study, reported in The BMJ as Research News, showed that many patients who present to the emergency department with cancer have not seen a GP, and this was commoner in those from deprived areas.6 7 Nine further studies appeared in The BMJ in the first six months of 2017, either as research papers or reported as Research News, which looked at patients’ access to services in relation to deprivation.8-16 Other reported studies that used big data mention using deprivation scores to adjust the statistical model in the analysis of their topic of interest, potentially forfeiting important understanding about the effect of socioeconomic status in patients’ access to services. The assumption that the NHS is equitable must be tested. International comparisons show us to have a small, inexpensive healthcare system. It inevitably functions as a competition between patients. We must measure the different effects of increasing financial pressures on the varying strata of society.

Competing interests: None declared. Full response at: http://www.bmj.com/content/358/bmj.j3188/rr-0. 1 2 3

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Iacobucci G. Exceptional requests for care surge as rationing deepens. BMJ 2017;358:j3188. doi:10.1136/bmj.j3188 pmid:28676479. Iacobucci G. Pressure on NHS finances drives new wave of postcode rationing. BMJ 2017;358:j3190. doi:10.1136/bmj.j3190 pmid:28676522. Judge A, Welton NJ, Sandhu J, Ben-Shlomo Y. Equity in access to total joint replacement of the hip and knee in England: cross sectional study. BMJ 2010;358:c4092. doi:10.1136/ bmj.c4092 pmid:20702550. Marmot M. The Health Gap: the challenge of health in an unequal world. Bloomsbury, 2015: 88. Murage P, Crawford SM, Bachmann M, Jones A. Geographical disparities in access to cancer management and treatment services in England. Health Place 2016;358:11-8. doi:10.1016/j.healthplace.2016.08.014 pmid:27614062. Abel GA, Mendonca SC, McPhail S, Zhou Y, Elliss-Brookes L, Lyratzopoulos G. Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data. Br J Gen Pract2017; DOI: https://doi.org/10.3399/bjgp17X690869 Mayor S. One in three with cancer diagnosed as emergency had not seen GP, study finds. BMJ 2017;358:j1993. doi:10.1136/bmj.j1993 pmid:28442494. Hippisley-Cox J, Coupland C. Development and validation of risk prediction equations to estimate survival in patients with colorectal cancer: cohort study. BMJ 2017;358:j2497. doi:10.1136/bmj.j2497 pmid:28620089. Wise J. Fixed second appointment improves breast screening attendance. BMJ 2017;358:j2360. doi:10.1136/bmj.j2360 pmid:28512140. Mayor S. Dental problems account for one in 140 emergency department visits. BMJ 2017;358:j98. doi:10.1136/bmj.j98 pmid:28069572. Mayor S. Emergency admissions for diabetes increase more quickly in deprived areas of England. BMJ 2017;358:j214. doi:10.1136/bmj.j214 pmid:28087499. Kmietowicz Z. Children’s diabetes control improves but gaps in care remain, audit finds. BMJ 2017;358:j1031. doi:10.1136/bmj.j1031 pmid:28246110. Torjesen I. Children who miss appointments may be at risk from lack of follow-up. BMJ 2017;358:j2983. doi:10.1136/bmj.j2983 pmid:28637672. Rutherford CA, Taylor-Robinson D. Wide variation in child mental health spend in England. BMJ 2017;358:j451. doi:10.1136/bmj.j451 pmid:28126737. Gulland A. Fall in rate of stillbirth drives down perinatal mortality. BMJ 2017;358:j3050. doi:10.1136/bmj.j3050 pmid:28642268. Wise J. Dying at home depends on wealth, location, and comorbidities, study finds. BMJ 2017;358:j547. doi:10.1136/bmj.j547 pmid:28148484.

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Access to care is not equal.

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