The social determinants of health are well-established, with consistent evidence of higher requirements for, and poorer outcomes from, healthcare in patients experiencing socioeconomic deprivation. Despite this, healthcare systems often struggle to address these inequalities, delivering care that is consistent with the Inverse Care Law; that “the availability of good medical care tends to vary inversely with the need for it in the population served”. Geographic isolation also poses challenges to the delivery of healthcare, particularly in emergency care, which often aims to respond to time-sensitive disease. The studies contained within this thesis describe associations between socioeconomic deprivation, geographic isolation, and use and outcomes across the spectrum of emergency care, from pre-hospital response to Emergency Department and critical care. The thesis primarily investigates how healthcare systems respond to health inequalities, but aims to recognise that the patients that use them are the central concern. Together, the studies find evidence of higher requirements for advanced intervention in the pre-hospital phase of critical illness, but poorer access to the pre-hospital critical care that might deliver it, for the most deprived groups. There is also evidence that the most deprived patients are more likely to experience potentially harmful delays in emergency care, and that Emergency Departments in the most deprived areas experience higher attendance rates and poorer performance. Evidence of poorer outcomes for patients experiencing socioeconomic deprivation is demonstrated in both systematic review and meta-analysis, and in a national retrospective cohort study examining the outcomes of emergency admissions to critical care in Scotland. Patients residing in the most isolated areas are shown to have lower admission rates to critical care than those in areas with more accessible healthcare. However, there is also evidence that the emergency care system responds to mitigate health inequalities in areas of geographic isolation, with increased pre-hospital critical care response and no difference in outcomes following critical care. The studies also contain evidence that may help clinicians and policymakers to respond to the inequities described, including in an intervention that may help to reduce the use of emergency healthcare for the most deprived, and in service design to mitigate the effects of the Inverse Care Law in emergency care.
Ryan D. McHenry (Thu,) studied this question.