No equity without equality: universalism,antiracism and the NHS

Abstract

The author takes issue with the switch within the UK’s National Health Service (NHS) from a framework of equality (based on its founding principle of universality) to that of equity (based on a supposed responsiveness to specific needs). It is precisely because people’s lives are structured by unequal exposure to risk, exploitation and harm that universal provision is necessary. Equality, properly understood, does not deny difference; it protects against hierarchy. He argues that the move to equity, far from being progressive in recognising difference, is actually based in neo liberalism’s domination of a market in which scarcity has to be managed, hence hierarchies established. Equity justifies differential access by framing it as fairness, instead of questioning why there is less to distribute. Racial equity metrics capture relative change rather than absolute improvement, allowing disparities between groups to narrow even as overall conditions deteriorate. Proportionality, on which equity is based, means sorting ‘populations’, and race, even if not intentioned, becomes an explanatory factor rather than a social marker. The task is not, argues the author, to refine inequality more humanely, but to reclaim equality as a universal social right and to confront the conditions that have deepened social injustices, which clearly affect health.