title: How a universal health system reduces inequalities: lessons from England.
abstract: Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period.
  
  
  
  Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare.
  
  
  
  Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare.
  
  
  
  Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Miqdad
authors.identifier: 0000-0002-3538-4417
authors.initials: M
authors.lastname: Asaria
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: Shehzad
authors.initials: S
authors.lastname: Ali
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Doran
authors.affiliation: Public Health England, York, UK.
authors.forename: Brian
authors.initials: B
authors.lastname: Ferguson
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich, UK.
authors.forename: Robert
authors.initials: R
authors.lastname: Fleetcroft
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Maria
authors.initials: M
authors.lastname: Goddard
authors.affiliation: Institute of Health Equity, University College London, London, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Goldblatt
authors.affiliation: School of Health Sciences, City University London, London, UK.
authors.forename: Mauro
authors.initials: M
authors.lastname: Laudicella
authors.affiliation: University College London, London, UK.
authors.forename: Rosalind
authors.initials: R
authors.lastname: Raine
authors.affiliation: Centre for Health Economics, University of York, York, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Cookson
mesh_terms: D004739:England; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D008137:Longitudinal Studies; D011320:Primary Health Care; D011787:Quality of Health Care; D012959:Socioeconomic Factors; D013222:State Medicine
keywords: ACCESS TO HLTH CARE; Health inequalities; PRIMARY CARE