Absent minorities?
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whole range of factors affecting people’s use of services. This framework is outlined in the following section and its implications for an understanding of ethnic patterns in the use of palliative care services are then illustrated throughout the remainder of the chapter. A MODEL OF HEALTH SERVICE UTILISATION Health economists conventionally view utilisation as jointly influenced by the supply of services – their location, ease of access, quantity and quality – and the demand for services, that is, the felt need for them in the (potential) user backed up by the material or social resources to make that felt need an effective demand. By contrast, public health professionals tend to regard need as an objective criterion, regardless of whether it is ‘felt’ by the potential user or not. In the public health model it thus becomes possible to identify ‘needs’ which are not demanded and which may or may not be supplied. ‘Demand’ here becomes a third factor mediating the interaction between need and supply according to a social logic regarding the potential user’s own valuation of their ‘need’. This is illustrated in Figure 8.1, which is derived from Stevens and Gabbay (1991). The figure shows that it is possible to have services which are either needed (field 1), demanded (field 2) or supplied (field 3) independently of the other fields. The aim of the health planner is to concentrate services into the intersection of the three primary fields such that they are needed, demanded and supplied (field 7). However, in looking at the use of palliative care services by people from minority ethnic groups we will be particularly interested in whether people from these groups are over-represented in: • field 1 (services which are needed, but neither demanded nor supplied); • field 4 (services which are both needed and demanded but not supplied); and • field 6 (services which are both needed and supplied, but not demanded). These all raise difficult policy questions which we address further in later sections. In the specific context of palliative care services for people from minority ethnic groups, field 1 – which we have labelled need –