Conference report: 50 years of the inverse care law

Stewart Mercer is a GP and Professor of Primary Care and Multimorbidity at the University of Edinburgh.

Carey Lunan is a Deep End GP and Chair of the Deep End Steering Group in Scotland.

Lynsay Crawford is a Deep End GP and Senior Clinical Lecturer at the University of Glasgow.

On 26 May 2021, the Scottish Deep End Group delivered a half day online conference entitled “50 Years of the Inverse Care Law” to mark 50 years since The Lancet published Julian Tudor Hart’s seminal paper describing the inverse care law.¹

Tudor-Hart described the inverse care law thus; “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. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.”¹

The conference reflected on the Inverse Care law, the origins of the GPs at the Deep End project in Scotland, and progress in tackling health inequalities in Scotland. One hundred and eighty seven people attended. Live tweeting was encouraged during the event, captured here.

The full summary of the conference can be found here.

The recorded presentations and discussion can be found here.

The inverse care law remains a significant problem in the UK, at its most visible in primary care in deprived areas (‘Deep End’ practices) characterised by high patient demand, complex needs, rushed consultations and stressed staff. There is a significant gap between what GPs and others in primary care are currently able to achieve, and what they could achieve with more time and resource.

Health inequalities primarily result from the unequal distribution of wealth and power across society, including the loss of community assets and social networks. However, access to healthcare is also a social determinant, and if the NHS is not at its best where it is most needed, the difference in health outcomes between the most and least affluent will continue to widen.

The Scottish Government has stated that it is committed to reducing health inequalities, which are ranked as some of the worst in Europe. The new Scottish GP contract has a focus on clusters of practices working together, with an expanded multidisciplinary team, and offers an opportunity to begin to tackle the inverse care law.

The GP as an expert medical generalist in deprived areas has a potentially key role in reducing or mitigating health inequalities. However, with recent workforce figures showing rising numbers of hospital consultants versus falling numbers of GPs, there is also an inverse medical care law [2]. There is clearly a pressing need for a new kind of general practice, designed and supported to meet unmet need in deprived areas.

The potential of general practice as a coherent system depends on a range of supporting and connecting infrastructures including resources (pro rata based on need), information, educational opportunities, research and evaluation, and career opportunities. To achieve this potential, the conference organisers drew up the following recommendations from presentations and discussion on the day.

Recommendations

1. The top priority is to tackle the inverse care law by allocation of additional funding to Deep End practices on a proportionate universalism basis.
2. GPs working in deprived areas should also have protected time for practice and personal development and wellbeing in recognition of the specific teaching and training needs to work in more deprived areas.
3. Ways of promoting and embedding continuity of care and long-term therapeutic relationships with patients with complex care needs is required. A learning cycle is required on what models work, whom they work best for, and with what outcomes.
4. The establishment of Health Equity GP leads within practices or Clusters in deprived areas, and the establishment of patient engagement forums to work within and between Clusters and health and Social Care Partnerships. This would facilitate collaborative working to tackle health inequalities and reverse the inverse care law.
5. Development of a pipeline of medical graduates who choose to work in general practice in areas of high deprivation. Evaluation of whether the current curricula prepare them for clinical practice in deprived areas is also needed.
6. Dedicated funding for research to rigorously evaluate these issues should be provided by the Scottish Government to the Scottish School of Primary Care at a level commensurate with that provided by the UK Government to the NIHR School for Primary Care Research in England.

References

1. Hart JT. The inverse care law. Lancet. 1971 Feb 27;1(7696):405-12. doi: 10.1016/s0140-6736(71)92410-x. PMID: 4100731.
2. Anderson M, O’Neill C, Macleod Clark J, et al. Securing a sustainable and fit-for-purpose UK health and care workforce. Lancet. 2021 May 22;397(10288):1992-2011. doi: 10.1016/S0140-6736(21)00231-2. Epub 2021 May 6. PMID: 33965066.

Footnote: Conference speakers

The conference was chaired by Dr Carey Lunan (Deep End GP and Chair of the Scottish Deep End Steering Group). The speakers were; Graham Watt (Emeritus Professor of General Practice at the University of Glasgow and founder of the Scottish Deep End Group); Sir Harry Burns (former CMO of Scotland); Dr Catriona Morton (Deep End GP and Deputy Director of RCGP Scotland); Stewart Mercer (Professor of Primary Care and Multimorbidity at the University of Edinburgh); Darren McGarvey (Scottish rapper know as Loki, hip hop recording artist, writer, columnist and social commentator), and Dr Naureen Ahmad (Head of General Practice Policy Division, and Policy Lead for Health Inequalities at the Scottish Government). Dr Becks Fisher (Deep End GP in London and Senior Policy Fellow at the Health Foundation) joined for the panel discussion.

 

Featured image by Andreea Popa at Unsplash