Emily Dobson

Emily Dobson





Emily Dobson


Saint Michaels Hospice, Harrogate








Could implicit bias at the point of referral to hospice services be attributing to inequalities?



In reviewing health inequalities it is not sufficient to simply focus on those most affected, instead there should be a whole systems approach to have the maximum effect upon the population. (1) Within such an approach ‘the mechanisms giving rise to inequalities are still imperfectly understood’.(2) Further it has been suggested that evidence remains to be gathered on the effectiveness of interventions to reduce inequalities, (3) particularly within end of life care (EOLC). (4)



To understand the mechanisms giving rise to inequalities in EOLC we utilised an adapted process map of the EOLC journey. (5) Within this map we highlighted pinpoints. Pinpoints are places within the journey where a clinician decides whether there is a referral to another service. At each pinpoint a patient profile was taken looking at their basic demographics (including disease and place of death) and index of multiple deprivation score.



The initial data review illustrated similarities across all the pinpoints with the exception of hospice care services that showed a significant increase in the number of patients classified within the 7 – 10 on the index of multiple deprivation and cancer diagnosis.


Further research – On going

At present statistical analysis is on going into the differences between the pinpoints. At the same time a literature review sought to analyse if there was evidence of a similar anomaly within another healthcare setting; in which it was identified that implicit bias was a potential cause. (6) The next phase of the research looks to test, using an Implicit Association Test method, whether implicit biases is present in the EOLC journey and develop an intervention to remove it.


  1. The Marmot review. Fair society, healthy lives [Internet]. [cited 2017 Jun 19]. Available from: http://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf
  2. Woodward A, Kawachi I. Why reduce health inequalities? J Epidemiol Community Health [Internet]. 2000 Dec [cited 2017 Jun 19];54(12):923–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11076989
  3. Linda Gottfredson. Intelligence: Is It the Epidemiologists’ Elusive "Fundamental Cause" of Social Class Inequalities in Health? J Personal Soc Psycology [Internet]. 2004 [cited 2017 Jun 19];86(1). Available from: http://psycnet.apa.org/?fa=main.doiLanding&doi=10.1037/0022-3514.86.1.174
  4. CQC. A different ending [Internet]. 2016 [cited 2017 Jun 19]. Available from: https://www.cqc.org.uk/sites/default/files/20160505 CQC_EOLC_OVERVIEW_FINAL_3.pdf
  5. Trebble TM, Hansi N, Hydes T, Smith MA, Baker M. Process mapping the patient journey: an introduction. BMJ [Internet]. 2010 [cited 2017 Jun 19];341. Available from: http://www.bmj.com/content/341/bmj.c4078
  6. Fitzgerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. [cited 2017 May 25]; Available from: http://download.springer.com/static/pdf/12/art%253A10.1186%252Fs12910-017-0179-8.pdf?originUrl=http%3A%2F%2Fbmcmedethics.biomedcentral.com%2Farticle%2F10.1186%2Fs12910-017-0179-8&token2=exp=1495709409~acl=%2Fstatic%2Fpdf%2F12%2Fart%25253A10.1186%25252Fs12