Beyond the inverse care law – the lasting legacy of Julian Tudor Hart.

Stephen Gillam is a general practitioner in Norfolk and Senior Visiting Fellow at the Institute of Public Health, University of Cambridge.

Irecall the moment with clarity: early 1973, sitting in a lecture room with other disciples listening to Anthony Giddens who was later to be embraced by New Labour as architect of the ‘Third Way’. The professor was expatiating on the merits of the Frankfurt School; I was struggling to understand a word. My mate Mick, an amiable anarchist from Liverpool and fellow sociology student, furtively thrust a xeroxed copy of the Lancet article into my hands. “This’ll be up your street”, he whispered, “he’s definitely one of us.” Half a century on, this article considers Tudor Hart’s legacy and contemporary salience.

The setting

Published in 1971, ‘The inverse care law’ remains the work most immediately associated with Julian Tudor Hart:‘The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.’ ¹

There was no doubting the historically variable quality of service, especially in inner cities. His own early experiences of practice in North Kensington might have been culled from the infamous Collings Report.² He had witnessed first hand the enormous improvements wrought in the delivery of medical care to previously deprived areas and populations. His particular concern was with the selective redistribution of resources required to deal with social inequalities in health. These appeared to be going in reverse. List sizes were increasing and a growing proportion of the population was living in under-doctored areas.

Tudor Hart was well aware that ‘medical services are not the main determinant of mortality or morbidity; these depend most upon standards of nutrition, housing, working environment, and education, and the presence or absence of war.’ ¹ That did not, however, justify defeatism in the face of glaring health inequalities. For this was an age of influential iconoclasts.

He dismissed the ‘showmanship’ of ‘Chairman Illich’ and reserved particular disdain for the ‘Liberal Retreat’ which was threatening to corrode the post-war social settlement that yielded the NHS.³ Thomas McKeown’s thesis implied a limited role for medicine in the historical reduction of mortality rates.⁴ This he carefully refuted in relation to today’s diseases such as diabetes and hypertension. Evidence for medicine’s contribution to lengthening life expectancy was also beginning to emerge.⁵

Political context was all. Struggling to meet expectations in the face of recurrent funding crises, the NHS was under fire in the early seventies from left and right. Keith Joseph, the Conservative secretary of state for social services, was advocating an insurance-based funding scheme while notional supporters such as Richard Crossman, Labour’s past equivalent, had propounded a regressive ‘NHS contribution’ and extending user charges. The welfare state itself was criticised for failing to narrow health and economic inequalities.⁶

Most of the paper was devoted to demonstrating the second part of his law. Three times communist parliamentary candidate and early member of the Socialist Medical Association, he remained passionately opposed to the operation of markets in health care throughout his life. He believed that the route to consistent improvement in the quality of primary care lay with salaried general practice.

Broadening the GP’s role

The ethical core of his Lancet paper is generally overlooked. Tudor Hart believed that re-distribution of medical care was imperilled most of all by ‘the isolated one-doctor / one-patient relationship, pushed relentlessly to its conclusion regardless of cost.’¹ Patient advocacy and the pursuit of optimal care was all very well but should not ignore the needs of other people. In this lay the limits to his appeal for many general practitioners.

GPs were, and remain, individualistic – placing a high price on their own autonomy, wary of centralization and the over-intrusive state. Albeit misguided by an obstructionist British Medical Association, they had resisted the establishment of both national health insurance and the NHS. A fee-for-service system was what most GPs claimed to want in 1911 and 1948. Tudor Hart regarded independent contractor status as a ‘quaint eighteenth century anachronism’. For many GPs, it remains a source of their adaptability and entrepreneurialism.

By the early 1970s, psychodynamic approaches to consulting had gathered considerable momentum.⁷ They readjusted the GP’s clinical focus: from disease diagnosis to the meaning of the illness, from the patient to the doctor / patient relationship. Tudor Hart was decidedly ambivalent about the mystical abstractions of Michael Balint. No need to explore hidden consultations where patients’ needs were self-evident. His openly Marxist view of the doctor’s place in society was in stark contrast to Balint’s Freudian analysis. He criticized the Balint model on three counts: as doctor-centred, for downplaying the organic despite its holistic philosophy, and for ignoring social context.

His own radical vision was of a ‘new kind of doctor’, responsible for the general public health of their neighbourhoods as well as for personal care.³ The epidemiologist Geoffrey Rose was contrasting high risk and public health approaches to disease prevention.⁸ Tudor Hart recognised that GPs, with practice lists covering 97%, of the population were uniquely positioned to resolve Rose’s ‘prevention paradox’. By identifying and treating those at high risk as well as managing other behavioural determinants, they could play a major role in improving population health.

Heading a primary care team, the ‘community general practitioner’, as well as retaining responsibility for acute illness, would be involved in searching for unmet need, in screening for preventable disease, in planning the continuing care of chronic disease, collecting health data and making these available to the local population annually.

His team’s landmark study in support of this vision was published thirty years ago.⁹ It represented the concrete culmination of his life’s work. He purported to show that assiduous audit and case finding in Glynncorrig had reduced the prevalence of cardiovascular risk factors and even mortality rates. The study was uncontrolled but the results were eye-catching. To read the paper today is to sense the twenty years of dedicated labour entailed, the practical challenges faced and overcome.

He battled gamely for his model with the BMA and the Royal College of General Practitioners. His proposals received little professional endorsement but the 1980s witnessed a steady resurgence of the preventive agenda in general practice.⁷ The NHS reforms of the following decade, however, were to realize his worst fears. Ironically, there were intriguing similarities in the language of Tudor Hart and proponents of the market he so abhorred.⁸ The authors of Working for Patients talked of producers and consumers. For Tudor Hart, the consultation was the point of ‘co-production’ of important health-related consumptions.³ Illness was a measure of the patient’s social and economic deficit, but he seldom sank into left-wing zealotry.

The evangelists of Evidence Based Medicine were to become unwitting foot soldiers in this brave new world. Quantification as an aid to decision-making fostered a growth industry in the production of guidelines, protocols and algorithms. This reached its apogee in the Quality and Outcomes Framework. Pay for performance nevertheless improved the quality of care and reduced variations in practice. It was always going to be hard to demonstrate its impact on mortality, in part because the most vulnerable last few per cent of any practice population are often the most difficult to access.

As inequalities in wealth have grown so have inequalities in sickness and death. New general practitioner contracts and funding formulae have tended to accelerate previous trends, promoting investment in high earning practices that serve affluent areas, where care is easier. Doctors themselves resisted the redistribution of health care funding he sought. Investment in practices whose earnings are lowest, whose patients are poorer and sicker, whose costs are higher, and whose clinical work is more difficult was regarded as ‘rewarding failure.’ As more affluent groups accrue the benefits of effective clinical interventions, the perverse effect of evidence-based medicine may be to increase relative inequalities in health.

Simpler calls

Tudor Hart’s influence endures at many levels. Michael Marmot acknowledged the continuing relevance of the inverse care law for his work in addressing social determinants.¹⁰ Leading acolytes such as Graham Watt have translated his ideas into various ways of meeting the particular health needs encountered by practices in deprived inner cities.¹¹ Beginning in Glasgow, the Deep End Project and similar networks are trying, under challenging conditions, to address health inequalities of access and supply. All practices nowadays continue to practice ‘anticipatory care’ under the terms of the QOF. His writings are as relevant to students of health care today as they have ever been. Among those who could recall the status quo ante, no-one has ever more powerfully made the case for a national health service among alternative health care systems.

Yet Tudor Hart’s over-riding message was more prosaic. Again and again, he emphasized how critical was personal knowledge of the local community and his patients in changing individuals’ behaviour. ‘Continuity, not salesmanship, will be the keystone of the applied medical science of the future, in which health workers and patients will work together to produce better health not as adversarial providers and consumers but as mutually respectful experts in the realities of care, measuring costs in real currencies of time and measured outcomes rather than the mindless reductionism of the market.’ ¹ We are entering an era when such continuity is harder than ever to sustain, despite mounting evidence of its benefits.¹²

I was privileged to work with Julian on various occasions. Combative but always warm, he forgave my Blairite apostasies when I returned to inner city practice. In later age, he was less the belligerent prophet and more sacerdotal. The Covid-19 pandemic has cruelly exposed the societal fault lines that impelled him. His strident voice echoes down the decades. Tudor Hart’s vision of the community general practitioner is yet to be realised on a large scale but the case for strengthening the public health function in general practice has never been more urgent.

References

1. Hart JT. The inverse care law. Lancet 1971; 1: 405-412.
2. Collings J. General practice in England today: a reconnaissance. Lancet 1950; 1: 555-85.
3. Hart JT. A New Kind Of Doctor. London: Merlin Press, 1988.
4. McKeown T. The Role of Medicine, Oxford: Nuffield, 1976.
5. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000; 355: 688–700.
6. Le Grand J. The Strategy of Equality: redistribution and the social services. London, George Allen & Unwin, 1982.
7. Gillam S. Of Patient Bearing – A History of General Practice in Eight Generations. Holt: Hill House Publishing, 2020.
8. Rose G. The Strategies of Preventive Medicine. Oxford: Oxford University Press, 1993.
9. Hart JT, Thomas C, Gibbons B et al. Twenty five years of case finding and audit in a socially community. BMJ 1991; 302: 1509-1513.
10. Marmot M. An inverse care law for our time. BMJ 2018; 362 doi.org/10.1136/bmj.k3216
11. Watt G. Reflections at the Deep End. Brit J Gen Pract 2012; 62: 6-7.
12. Pereira-Gray D, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors – a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018; 8: 6. http://dx.doi.org/10.1136/bmjopen-2017-021161

Featured photo by Edward Howell on Unsplash