ESSAY

Essay

The inverse care law today

Graham Watt
The availability of good medical care tends to vary inversely with the need for it in the population served1

When Julian Tudor Hart described the inverse care law in 1971, he was principally concerned with the effects of market forces on health care.1 Then, as now, the private sector was being invoked to provide solutions to problems in health-care delivery, but, as Hart said, no market will ever shift corporate investment from where it is most profitable to where it is most needed.2 In this sense the inverse care law remains true, for in every society where market forces determine who gets what in health care, inequalities are a major feature of the system. The fact that the inverse care law remains true in the British National Health Service (NHS), however, where financial barriers to care have been largely removed, means that other processes are at work. The original paper is no longer sufficient to describe and explain this problem.

Medicine works
In an influential book,3 also published in the 1970s, Professor Tom McKeown claimed that health services had contributed little to improvements in public health. Looking back over 100 years, this observation was largely true at the time. The first randomised controlled trial took place at the same time that the NHS was set up. Looking back over the past 50 years, however, McKeowns statement is no longer true. There is now a substantial armamentarium of interventions of proven effectiveness in altering the natural history of serious conditions. Because many of the most effective interventionseg, prevention of complications in patients with coronary heart disease and diabetes, and reversal of risks due to raised blood pressure and cholesterolare applicable to large numbers of people, these developments have the potential to make great contributions to improving public health. In view of the scale of their application, they have probably had such an effect. The results of a review of trends in coronary mortality,4 in 31 populations in the 10 years from 1984, indicate that about half of the observed reduction in mortality could have been due to clinical interventions.

of the population because they recognise that the work involved in recruiting the last 20% could be as great as that involved in recruiting the first 80%. Primary healthcare teams have no such option. They provide care for 100% of their populations, including the people that epidemiologists find difficult to study. This observation has two important consequences. First, with the same resources, primary health-care teams in deprived areas, initiating programmes to prevent disease complications and to reverse risks, will achieve less. For example, treatment rates for antidepressant medication and cholesterol lowering with statins are both lower than expected in the bottom quintile of the distribution of socioeconomic status.5 Second, deprived areas are less likely to be represented, not only in epidemiological studies, but also in randomised controlled trials and other studies relevant to clinical practice. Several systematic reviews of the research literature have been done to establish what the NHS can do to address inequalities in health. This process is biased. First, the availability of research evidence is socially patterned and tends to exclude populations with the greatest degree of health need. Second, research frequently focuses on narrow questions, concerned with the management of specific conditions, rather than the effectiveness and efficiency of primary care as a whole system.

Comorbidity
Barbara Starfield argued that there is no good evidence base for diagnosis and intervention in primary care, where the nature of the problems and the extent of comorbidity make irrelevant the application of most clinical guidelines.6 She was writing generally, and not from a UK perspective, but what she said is particularly true of the type of comorbidity that is seen in deprived areas. The comorbidity of socioeconomic deprivation needs to be distinguished from the multiple pathology that is common in elderly people. Comorbidity in deprived areas comprises the number, severity, and complexity of health and social problems that exist within families. Not only are such problems concentrated within families, such families are concentrated within practices, and, in many parts of the country, such practices are concentrated within areas. Yet most evidence, guidelines, health-technology assessments, national service frameworks, and health policies are based on the assumption that individuals have single conditions. The most prevalent comorbidity is psychological distress. The obvious response is to encourage the identification and treatment of affected individuals, but what are the implications for a doctors surgery in which the social patterning of mental ill health results in twice the national prevalence of depression, and in which a

The problem of non-response

In studies that involve the general population, epidemiologists believe they have done well if they achieve response rates of 80%. In studies done in areas affected by severe socioeconomic deprivation, a response rate of 60% is judged respectable. Epidemiologists tend to try not to recruit the remainder
Lancet 2002; 360: 25254
Department of General Practice, University of Glasgow, Glasgow G12 0RR, UK (Prof G Watt FmedSci) (e-mail: gcmw1j@clinmed.gla.ac.uk)

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large proportion of consultations for common conditions take place against a background of measurable psychological distress? The results of a study of consultations done by family doctors in Glasgow7 indicate that as the practice deprivation score went up, so did the prevalence of psychological distress. Although patients with psychological distress had longer consultations than mentally healthy patients, average consultation times were shorter in practices with higher deprivation scores, suggesting that consultations without an element of psychological distress must have been very short indeed. This report begins to capture the reality of practice in deprived areasa reality that often fails to register in official documents and reports. In the early days of general practice in the NHS, Collings observed, some conditions of general practice are bad enough to change a good doctor into a bad doctor in a very short time.1 The modern equivalent is that some conditions of general practice make the delivery of effective medical care difficult.

Confounding the inverse care law

Julian Tudor Hart practised what he preached, combining the skills of epidemiology and clinical medicine within a single population. In 1991, he reported the results of 25 years of case finding and audit in a socially deprived community.8,9 Compared with a neighbouring village, which had similar amounts of severe socioeconomic deprivation but a more traditional approach to medical care, premature mortality was 28% lower in his village at the end of the period. Although not a rigorous scientific experiment, Harts is the only evidence we have concerning the long-term effect of a system of care, delivering evidence-based medicine with careful targeting of high-risk patients, doctors working closely with nurses and receptionists, keeping high quality records, and using audit to measure what has been achieved and what has not been done. Such work is much easier to do now. Perhaps the difference in mortality would have been greater if the high-risk strategy had included cholesterol-lowering. This anecdote, comprising a lifetimes work, raises many questions.10 Julian Tudor Hart was not only the epidemiologist who did not go away; he was also the personal doctor who knew his patients well, could see problems in their family and community context, and worked with patients over many years to reverse risks and prevent complications. Could it be that the answer to comorbidity in deprived areas is a personal doctor?

Second, the policy-making process lacks essential information from routine data and from research. A classic example of this limitation was provided by Fair Shares for All,5 which attempted to establish a formula to redistribute NHS resources in Scotland according to need. Need was identified on the basis of health-service activity, as recorded by about 50 general practices involved in a continuous morbidity recording project. Few practices in the scheme came from deprived areas and no data were available for unmet need. The report concluded that the two health boards most affected by socioeconomic deprivation, comprising 29% of the Scottish population, but including 65% of areas in Carstairs deprivation categories 6 and 7, should receive 29% of the budget for general medical services (general practice). Despite the best of intentions and the best methods of statistical and economical analysis, the exercise largely failed to redistribute resources within primary care. Third, there are poorly informed views of what has been tried. In a recent book, Did Things Get Better?, reviewing the achievements of the present Governments first term, Polly Toynbee commented that, during decades when the NHS had distributed money to bad health areas from rich ones, the health gap widened, showing how little real difference the NHS makes.11 That a leading social commentator should get this issue so hopelessly wrong is a measure of current orthodoxy. The reason the NHS makes little difference is that money has not been redistributed. Deprivation payments, even in their new improved form, do not shift money from rich areas to bad health areas, at least not in the way that is generally perceived. Their main effect is to create a level playing field, based on the incomes of family doctors, so that there is more likelihood of recruiting and retaining general practitioners in deprived areas. A better analogy than the playing field is a swimming pool. Everyone who can be seen has their head above water. Family doctors in affluent areas are standing in the shallow end with their feet on the bottom, whereas those in deprived areas are treading water in the deep end, receiving deprivation payments for their trouble. This analogy is not to suggest that family doctors in affluent areas are not busy, or that they do not have demanding patients. Everyone is busy, but busy with different problems. In the UK as a whole, practices serving areas in Carstairs deprivation categories 6 and 7 have twice as many deaths under age 70 years as practices that serve affluent areas in deprivation categories 1 and 2.

Obstacles
Whatever the lessons to be learned from this example, major obstacles stand in the way of policies to counter the effects of the inverse care law. First, there is inadequate recognition of the contributions that clinical services make to public health, and the extent to which correction of variations in service delivery might contribute to public-health gain. Neither the Scottish nor the English policies to address inequalities in health recognise the inverse care law as contributing substantially to the problem. Instead, public-health orthodoxy still embraces McKeown. Increasingly, primary health-care teams have been encouraged to embark on interventions of unproven effectiveness outside their traditional areas of activity, for which the opportunity cost might be failing to improve the delivery of interventions of proven effectiveness within their traditional areas of activity.

Conclusion
Harts original paper, introducing the inverse care law, was not a systematic review of evidence but a polemic describing the effect of market forces on health care. Then, as now, there was less evidence than one might expect. Although commercial solutions to health-care problems are still a threat to public-health equity, this is no longer the most important formulation of the inverse care law in the UK. As affluent groups accrue the public-health benefits of effective clinical interventions, the perverse effect of evidence-based medicine will be to increase inequalities in health. A major stumbling block to progress is the absence of routine and research data quantifying the added costs of clinical effectiveness in deprived areas. Until this work is done, deprived areas will continue to lose out in NHS resource distribution formulas. We need more from our politicians and policy advisers than whole-hearted commitment to reduce inequalities

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in health. Intellectual opposition to injustice is only the beginning of social understanding. Solutions must be framed in causal explanations of the problems being addressed. We need policies that will make a difference and resources to ensure that good medical care is provided where it is most needed.
Acknowledgments
I thank Julian and Mary Hart for many years of friendship and inspiration. The views expressed are mine alone.

References
1 2 3 4 Hart JT. The inverse care law. Lancet 1971; 1: 40512. Hart JT. BMJ 2001; 322: 136364. McKeown T. The role of medicine: dream, mirage or nemesis. London: Nuffield Principal Hospital Trust, 1976. 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: 688700 5 Scottish Executive Health Department. Fair shares for all: report of the National Review of Resource Allocation for the NHS in Scotland. Edinburgh: Scottish Executive Health Department, 1999. 6 Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001; 51: 30309. 7 Stirling AM, Wilson P, McConnachie A. Deprivation, psychological distress, and consultation length in general practice. Br J Gen Pract 2001; 51: 45660. 8 Hart JT, Thomas C, Gibbons B, et al. Twenty five years of casefinding and audit in a socially deprived community. BMJ 1991; 302: 150913. 9 Kaul S. Twenty five years of case finding and audit. BMJ 1991; 303: 52425. 10 Watt GCM. The example of Dr Julian Tudor Hart. Br J Gen Pract 1999; 35: 503. 11 Toynbee P, Walker D. Did things get better? An audit of Labours successes and failures. London: Penguin, 2001; 87.

Uses of error
Checks and balances
Richard Hobbs Arriving to do my first 2-week clinical placement as a fourth year medical student, I was informed by the consultant that the house officer was sick and I would replace him for the duration. I was pretty shocked, not that I could show it. I knew remarkably little medicine: lots of theory but little practice. That 2-week stint was a formative experience: I gained fantastic clinical exposure and mugged-up in the library on my nights off. My saviours were excellent senior house officers, but pride prevented me from involving them too frequently, hence my first big clinical error. An elderly man was admitted with chest pain and shortness of breath. I diagnosed a myocardial infarction and used the normal range of drugs available in the pre-thrombolytic days. However, his condition did not stabilise despite my best efforts and I couldnt quite work out why, although I thought he was in congestive heart failure. It was the early hours of the morning and I didnt want to wake my senior house officer again. Despite significant reservations, I decided to give the patient some diamorphine as was advised in the books. He died 30 min later and I spent the rest of a sleepless night panic-struck that I had killed him with my morphine bolus. I couldnt bring myself to talk about it but awaited the post mortem in trepidation that my career would end before it had begun. The post mortem revealed that he had suffered a pulmonary embolus. No one seemed to notice the fact that I had missed it. This error left me with an increased interest in the diagnostic process and less reluctance to seek advice. My second big error, or rather lesson, was in my early years as a general practitioner in a difficult inner city practice. We did 11 clinics a week each which were often long and packed with extra patients. Demands were excessive and I adopted a somewhat gung-ho approach to patients wishing to be seen on an emergency basis for a problem of convenience. I would start the consultation with a lesson on why it was not appropriate to abuse the appointment system (we ran 10 min appointments even in those days). To some of my more pugilistic patients, a red mist would descend and a difficult consultation would ensue. One evening a mild-mannered chap who had received my lesson of the day paused at the door and suggested I should check a patients history before complaining about their use of the service. It transpired that he had recently been released from prison having served a second term for grievous bodily harm. To avoid ongoing anxiety I called and apologised on my way home that evening. This communication error taught me to be more selective with what I say to patients. I remain as reluctant as ever to respond to unreasonable demands, but I am much more polite about it. Many of my subsequent errors relate to a delay in diagnosis; the inevitable consequence of investigating undifferentiated symptoms is that serious problems may only become obvious after several consultations. In most cases, a diagnosis might have been made earlier, but this is always easy in hindsight. However, such delays can appear as stark errors in the minds of family members. I wish it were possible to openly discuss why one managed cases in a particular way, rather than defend oneself against the backdrop of complaints and medical negligence claims. Unfortunately, the system does not allow doctors to make errors.

Department of General Practice, University of Birmingham, B15 2TT, UK (Prof R Hobbs FRCGP)

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