There are many threats to healthcare world-wide and they mostly relate to access to care. In this blog I return to the issue of equity in healthcare delivery and improvement, which also influences access and safety. I have discussed this topic before in several blogs and I am coming back to it now, given the headlines in the United States, where diversity, equity and inclusion programmes are under intensive attack.
An editorial in the Lancet[i] on equity in Ireland last year focused on the gains made and the future challenges faced. Sláintecare will go a long way in addressing the equity challenge. Diversity and inclusion are an important HSE strategy.[ii] As demand for healthcare grows, so does the problem of waiting lists in all parts of healthcare. Disadvantaged patients do not have the option of the private sector so it is inevitable that we will have an equity problem.
We need to look at what is happening in our services and make sure that we address the challenge of providing equitable care. It is important that we ensure everyone has an equal chance to receive care, no matter who they are in terms of gender, ethnicity, sexuality, neurodiversity; or where they live, i.e. rural, urban or inner city.
We should focus on how we can achieve equity. For example, a recent study in the UK focussing on primary care showed that equity remained an issue, and I am sure it is no different here.[iii] Recently, several papers have been published that look at equity, which shows that there is a growing interest in this area.[iv] [v] [vi] [vii] All have similar themes, which I will summarise in the rest of the blog.
Equitable care must be a core value that we hold and believe in. It is not an add-on but central to all the services we deliver. This will require leadership from the executive and management team that enables the clinical staff to deliver healthcare. Leadership for equity means that we talk about equity on a daily basis, along with the provision of resources to address the problem. This includes the need to address implicit biases about how care is received and what the person’s lived experience of care is actually like.
We need to assess our cultural competence as Ireland becomes a more diverse society. Leaders need to understand the equity challenge in their own context and how the wider system impacts on the equity of care. They should ensure that the staff employed reflect the community that they treat, and that they are supported for equity. Data is essential and should be segmented as per the context, so that one can see where inequity is occurring. This will provide the evidence for proactive interventions to address the inequity.
In quality improvement and patient safety initiatives, equity of care should be a priority. The question to ask is whether the quality improvement initiative benefits all equally. It is often assumed that if an improvement initiative is successfully implemented, the care will improve for all. However, a programme may make no difference to the equity gap, or it may widen the gap. If the programme is well designed, it will reduce the gap. For example, for a programme in the hospital to decrease waiting times in a clinic, if we do not have an equity focus, we can improve the average waiting time but not the waiting time for the most disadvantaged patients.
Solutions to the equity challenge must be codesigned and coproduced with patients and families and their kin. This must be an equal and reciprocal partnership, which is different from the usual consultation model used in healthcare.
Finally, we cannot assume we are providing equitable care or that the problem is too big to be addressed. It is an imperative from which we cannot escape.
Across Ireland, social inclusion clinics are being established. While these may be a good and valuable short-term solution, I would argue that the system needs to fundamentally change so that equity is in the mainstream of all that we do.
[i] The Lancet (2024). Health equity in Ireland: past, present, and future. Lancet (London, England), 403(10433), 1205. https://doi.org/10.1016/S0140-6736(24)00628-7
[ii] HSE Diversity, Equality and Inclusion https://healthservice.hse.ie/staff/procedures-guidelines/diversity-equality-and-inclusion/
[iii] Barrell, A. M., Johnson, L., Dehn Lunn, A., & Ford, J. A. (2024). Do primary care quality improvement frameworks consider equity?. BMJ open quality, 13(3), e002839. https://doi.org/10.1136/bmjoq-2024-002839
[iv] Lion, K. C., Faro, E. Z., & Coker, T. R. (2022). All Quality Improvement Is Health Equity Work: Designing Improvement to Reduce Disparities. Pediatrics, 149(Suppl 3), e2020045948E. https://doi.org/10.1542/peds.2020-045948E
[v] Hirschhorn, L. R., Magge, H., & Kiflie, A. (2021). Aiming beyond equality to reach equity: the promise and challenge of quality improvement. BMJ (Clinical research ed.), 374, n939. https://doi.org/10.1136/bmj.n939
[vi] Johnson, L. L., Wong, G., Kuhn, I., et al. (2025). A realist review of how, why, for whom and in which contexts quality improvement in healthcare impacts inequalities. BMJ quality & safety, bmjqs-2024-017386. Advance online publication. https://doi.org/10.1136/bmjqs-2024-017386
[vii] Jomy, J., Lin, K. X., Huang, R. S., Chen, A., Malik, A., Hwang, M., Bhate, T. D., & Sharfuddin, N. (2025). Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine. BMJ quality & safety, 34(2), 120–129. https://doi.org/10.1136/bmjqs-2023-017022
