Potential health system responses to health inequities include health promotion, higher treatment levels for targeted populations, more effective treatment (eg, given earlier, or with better compliance) and improved use of resources through better coordination and information sharing.9 The data above indicate that, although a multi-pronged approach will be necessary, the largest population benefit will be through making prevention programs more effective. Well-documented differences in chronic disease risk behaviours include higher prevalence of smoking, obesity, and high blood pressure in low SES groups.3

How prevention strategies can be more effective among low SES groups is the subject of much controversy and little systematic research. Many authors believe that traditional approaches to health promotion will not be effective because the capacity to make “healthy” choices is strongly linked to environmental and social factors that accompany poverty and disadvantage. Determinants of health can be considered at upstream (social, physical, economic and environmental), midstream (psychosocial and health behaviour), and downstream (individual) levels.10 Health promotion within clinical services has traditionally focused on the individual level, although public health preventive activities have generally had the most effect when implemented at upstream levels. Given the limitations of the existing evidence for reducing socioeconomic health inequities, interventions that have been effective with other health problems are a good starting point.11

Australian data on potential differential access to services are limited and largely confined to geographic access for people in rural and remote areas. There is no whole-of-population dataset that systematically looks at the quality and effectiveness of care for chronic disease in groups experiencing health inequities. However, studies suggest there is much room for improvement. For example, in 98 000 general practitioner encounters, holders of healthcare cards (who are on aged, disability, unemployment or other low-income pensions) were more likely to have chronic diseases and fewer preventive measures (such as Pap smears).12 At the tertiary care level, patients of lower SES had less access to invasive procedural treatments following admission for coronary heart disease in Queensland.13

As our healthcare system is oriented to acute care, chronic care treatments that reduce disability (eg, joint replacement surgery) are likely to have lower priority and therefore be more difficult to access. Such inequities of access may be greater for dental care, physiotherapy, speech therapy, dietetics and podiatry, which are not subsidised outside public hospitals. Thus, in redistributing resources for health problems where inequities exist, it is important to ensure that the investment is made where the effect is likely to be greatest.

Achieving continuity of care across healthcare sectors is a major problem in the care of people with chronic disease, especially those disempowered by way of income, language, or culture. Delivery of care and support services by multiple professionals and agencies compounds the problem. Appropriate rationalisation of such arrangements and good coordination of care can lead to better outcomes.

Any attribute of our healthcare system that impairs any health outcome will be compounded for people who are poor or otherwise disadvantaged. Indeed, it will be difficult to redress health inequities for people with chronic disease without addressing the broader problems in the system. However, without specific attention to health inequities in research, planning and policy (see Box), the current differences will not go away, and may even increase.