We therefore checked our main results with the secondary (longitudinal) analysis, which assessed subsequent diagnosis in those had met the criteria for ‘illness burden’, and subsequent treatment in those with a medical diagnosis, but the number supplier WAY-100635 of participants who could be followed through the waves in this way was too small to allow meaningful conclusions to be drawn from the results. Our results fit with previous findings that a greater proportion of people in deprived groups had Rose Angina, but there was no difference in the proportions receiving a general practitioner diagnosis of coronary heart disease.14 Care-seeking behaviour and patient preferences

may differ with wealth. Given the same information, patients may want fewer medical interventions than their doctors recommend33 34 and pessimism about availability of treatment may make older people reluctant to seek help.35 Older people may view living with symptoms (such as pain, or emotional problems) as a normal part of ageing.36 The response of the primary care physician may also vary with the wealth of the patient. For example, the physician might be more likely to consider symptoms of breathlessness as a medical problem requiring a diagnosis, whereas aches and pains, poor vision and low mood might be considered part of the tapestry of life, or the natural ageing process. Comorbidity is more common

in deprived populations, and may make diagnosis of all conditions harder for doctors within the constraints of a short consultation.37 At a system level, the results may be partially explained by wealthier people living in areas where there are more healthcare resources. Wennberg introduced the concept of ‘supply-sensitive care’ to describe how the quantity of healthcare resources allocated to a particular population was a major determinant of the frequency of use of health services by that population, and gives an example in which “a doubling

of the supply of internists or cardiologists results in roughly a halving of the interval between repeat visits.”38 39 Where healthcare resources are relatively plentiful, patients with chronic diseases will consult more, use more diagnostic tests and be referred to hospital more. Further research could helpfully investigate whether those missing out on diagnosis are not accessing health services, or are seeing a doctor but not being diagnosed. The participants were selected to be nationally representative of the population of England, and so the findings are likely to be generalisable to England, Carfilzomib but not to countries with different healthcare systems. If validated, our findings that inequalities in receipt of diagnoses are potential barriers to equitable healthcare for five common long-term conditions suggest that future policy interventions to reduce socioeconomic inequalities in healthcare should consider improving access to diagnosis as well as treatment. Supplementary Material Reviewer comments: Click here to view.