Introduction

Although the term equity did not feature in early policy documents related to the English National Health Service (NHS), equity was one of the main policy goals at its inception in 1948 (Delamothe, 2008). A particular concept of equity remains one of the central NHS principles, which state that, ‘it meet the needs of everyone, […] be free at the point of delivery [and] […] be based on clinical need, not ability to pay’ (NHS England, 2015a).

The current literature on equity in healthcare distinguishes between horizontal equity, requiring that equals be treated equally, and vertical equity, requiring that unequals be treated unequally (Mossialos and Dixon, 2002). For a healthcare system to be equitable, both concepts of equity need to be respected in financing and the distribution of services in the population. This requires that contributions be levied based on ability to pay and access to services be based on need.

In the context of an equitable distribution of services, frequently discussed notions of equity include equality in utilisation of care by those in equal need or equality in health outcomes (Powell and Exworthy, 2003). However, such policy goals may be undesirable or, at best, difficult for a health system to achieve. They would require public policy to impinge heavily on personal choices and life styles (Oliver and Mossialos, 2004). Also, the determinants of health have been shown to lie largely outside the realm of healthcare (Marmot, 2010). As a result, there is now a relatively broad consensus among researchers that equity of access is a more appropriate policy goal for healthcare. As Oliver and Mossialos (2004) have concluded, this is because equity of access

To the extent that the combination of taxes from which healthcare is funded remains progressive overall, funding from general taxation ensures equity of financing in the English NHS.