Conditional care

Should access to care depend on how well you look after your own health?

Photo by Aniskov, CC BY-SA 4.0

Louise Laverty and Rebecca Harris, “Can conditional health policies be justified? A policy analysis of the new NHS dental contract reforms”. Social Science and Medicine, v. 207, June 2018 (46-54).

Is it ever fair to offer patients differential care based on whether they are taking adequate care of themselves? Laverty and Harris attempt to answer that question by doing a textual analysis of conditional NHS dental policies, implemented in 2009, that restrict patients with a history of poor oral health from accessing the full complement of NHS dental services until they are vetted through a series of preventative care check-ups. They found that the conditional policies implemented by the NHS disproportionately disadvantage patients who are already marginalized, undermining NHS core principles of universality, treatment according to need and no cost at the point of service delivery.

The conditional policies implemented by the NHS ask dentists to utilize care pathways, or standardized diagnostic processes, to sort patients based on their medical history and socioeconomic information into three streams: Green (healthy, with biennial checkups and a full range of services), Amber (relatively healthy, with annual checkups and a full range of services), and Red (patient has an active disease, is refused advanced care within the NHS until they prove that they can improve their dental hygiene and diet, and has to pay for routine preventative check-ups). Dentists do have the ability to override this system by discretion, which Laverty and Harris see as problematic given the lack of oversight in how these policies are suspended, as well as the notion that dentists might cherry-pick patients to improve patient satisfaction scores that would increase renumeration.

Proponents of conditional policies justify them by a mixture of approaches, including the contractualist notion of governments and citizens having a duty to each other to prevent abuse of the system, the paternalistic stance of conditional policies being in the best interest of the patient to resist dependency, and the mutualist argument which states that conditionality is best for the majority. Laverty and Harris note that these arguments, spurred by Britain’s focus on austerity after the Financial Crisis of 2008, are bolstered by a societal discourse of stigmatization between the ‘deserving’ and ‘undeserving’ poor. The authors argue that there is a lack of evidence that conditionality works, and that patients who are non-compliant are likely so because they are unable to comply given the barriers they face to attending appointments during working hours, paying for frequent treatment, and accessing services.

Laverty and Harris expose an important flaw in the logic of conditional policies in healthcare. By shifting responsibility onto patients, conditional policies neglect structural inequities and may serve to exacerbate health issues for those who are most marginalized.


- Tari Ajadi


Tag: health equity