Rachel Horton, University of Reading
Discrimination, Equality and Health Care Rationing was published by Bristol University Press in June 2025.
What is the book about?
The book is about the potential and limits of equality law (including the Equality Act 2010 and the Human Rights Act 1998) to prevent discrimination in access to healthcare and to address health inequalities in the UK. Much of the research on health inequalities has focussed, rightly, on the relationship between health and socio-economic status. However, there has been increasing interest in understanding health inequalities that relate to personal characteristics such as sex, race and age, and the part discrimination may play in causing or perpetuating these – both as a determinant of poor health and as an explanation for uneven access to healthcare. The first half of the book explores the obligations and constraints that arise in deciding what health care should be funded by the NHS, and for whom, and how these obligations have been, or might be, interpreted by the courts. The second half then explores the application of equality law in three different contexts: public health, including the public health response to COVID, access to fertility treatment and intensive care.
Why did I write it?
A number of years ago I became involved, through one of my colleagues, in advising a committee that sets priorities for local health spending on their obligations under the Equality Act. It soon became apparent that health care commissioning gives rise to a number of interesting and difficult questions about the application of equality law. Examples include whether same-sex couples should be able to access IVF in the same way as heterosexual couples; whether age limits for access to IVF or cervical or breast cancer screening programmes are acceptable; and what role, if any, age and disability should play in the allocation of intensive care beds when there are not enough for everybody. Problems of discrimination and equality were brought into sharp focus during the COVID pandemic where the unequal impact, not only of the virus but of the public health responses to it, has been well documented.
How did I go about doing this research and what further work is needed in this field?
There has been very little previous research which explores the intersections of equality law and access to healthcare. Much research on equality law is – understandably – in the field of the labour market where it has its origins and there has been very little case law on access to healthcare. The book brings together literature and law on health inequalities, access to health care and equality law with the aim of generating useful insights for those engaged in health law and health care research and policy and to help to identify gaps in our current understanding and areas for future research.
There is plenty of scope for further work in this area. We know very little, for example, about when – and how – individual clinicians use protected characteristics in their decision making. We also need to understand better the challenges faced by those commissioning healthcare in taking equality considerations into account (for example when exercising the Public Sector Equality Duty). How, for example, might institutions be given more confidence in the boundaries of permitted positive action so as to take steps to address inequalities? Finally, research would be useful to understand, given the limited case law to date, why equality law appears to be relatively underutilised in this context and whether that is something that should concern us.