There are of course methodological limitations: ward standardized mortality ratios were used to assign levels of need to practices, yet these ratios do not necessarily refer to the current health status of the practice population Gillam, This study is important however, in exposing the scope of the Inverse Care Law — it is not just in the likelihood of diagnosis or quality of treatment people receive that healthcare is found to be inequitable, but before these stages of illness are even reached, those with more need miss out on such services that could prevent or at least lead to early detection of illnesses.
Motivated by the lack of research on how the Inverse Care Law operates, Stewart Mercer and Graham Watt carried out a questionnaire study on 3, NHS patients attending 26 general practitioners, 16 of which were in the most deprived areas and 10 of which were in the least deprived areas of West Scotland Mercer and Watt, It is noted in the study itself that this was carried out before the introduction of the 48 hour access target set by the UK Government, which may have had a significant effect on access as well as patient satisfaction with access Mercer and Watt, However, if this description holds true then if anything this study can be said to possibly underestimate the effects of the Inverse Care Law in primary care.
Not only is this study the most recent of those discussed but it is also comprehensive; in analysing a more extensive range of ways in which the Inverse Care Law can be said to affect health care it provides the strongest support for the argument that the Inverse Care Law is still relevant today. Whilst the studies discussed so far are characteristic of the majority of studies on the Inverse Care Law it is important to consider research findings against the Inverse Care Law.
Using data from the UK Quality of Outcomes Framework, a voluntary scheme set up to encourage good practice and quality of service amongst doctors, by offering financial rewards for points achieved from a range of good healthcare indicators NICE, ; The NHS Information Centre, , Strong, Maheswaran and Radford present an ecological study, testing previous findings that the provision of healthcare for patients with coronary heart disease is unequal Strong et al, Whilst it was found that coronary heart disease was more prevalent in deprived practices, contrary to previous findings and predictions of the Inverse Care Law, they found no evidence of inequality in healthcare for coronary heart disease, in fact the only quality of care indicator that did correlate with deprivation was in the case of smoking status and this showed a positive relationship, suggesting the possibility of better care in deprived areas for this condition Strong et al, However, as the findings of this study appear to be the exception rather than the rule more evidence needs to be collected in support of these conclusions, especially considering that the Quality of Outcomes Framework appears to be a controversial measure of the quality of healthcare provided Guthrie et al, Whilst one study discussed has found evidence contradictory to the Inverse Care Law the overall consensus of the studies is that the Inverse Care Law still exists today, whether it is in the case of diagnosis and management of depression, availability of health promotion clinics, access and consultation length or waiting time for surgery.
Options for the NHS in a consumer age As well as issues already raised by the studies discussed, Seddon adds to the significance of the association between socio-economic deprivation and longer waiting times; he reasons that longer waiting times are not merely an inconvenience but stresses that the waiting itself can actually make you ill, referring to one study that found 21 per cent of lung cancer patients to be unsuitable for curative treatment following their wait for radiotherapy Seddon, Seddon also discusses a study on total elective hip replacement which shows a clear mismatch between those who showed greater prevalence and severity of hip disease and those who received surgery Seddon, In emphasising the importance of this issue of healthcare inequity, Seddon quotes the estimated number of avoidable deaths in relation to one study of emergency procedure on fractured neck of femur Seddon, Beyond problems of access to primary care, in relation to secondary and tertiary services Seddon alludes to the problem of lower referral rates for lower-socioeconomic groups Seddon, Firstly that this relationship between need and health services continues despite numerous policies put in place since which have actively sought to invest extra resources and money into poorer areas, for example the Allocation of Resources to English Areas Sutton et al, which sought to calculate and distribute resources to areas based on need.
For example the study of depression by Chew-Graham et al highlighted the significance of GP attitudes and bias on the process of diagnosis and treatment Overall the interaction between socioeconomic class and the GP-patient relationship may play a serious role in the inequity of health services.
It is clear from the literature reviewed that the current consensus is that the Inverse Care Law still plays a significant role in the NHS. The majority of studies focus on the Inverse Care Law in relation to one particular condition and a lot of the samples are based in Scotland and not representative of the whole of the UK. Moreover, considering there have been recent changes to healthcare policies and initiatives, including the implementation of the Qualities and Outcomes Framework, a lot of this data is already outdated.
This is important to investigate because if the problem does stem from GP-patient relationships and the clashing of social class then it suggests that rather than redirecting resources to solve the problem, it would be more beneficial to educate GPs to make them aware and reflective of these issues, as well as specifically target and encourage those from lower socioeconomic backgrounds to use the health services; the implications for policy are therefore great.
In areas with high needs, such as inner cities and deprived areas, there tend to be fewer doctors working with higher caseloads and sicker patients. Although GPs are encouraged to work in 'underdoctored' areas through a system of incentives, these have not enticed enough GPs to work in the poorest areas. Other evidence suggests that there are problems with the service some GPs are delivering in deprived areas.
For example, the National Survey of NHS patients' attitudes to General Practice in showed that a significantly higher proportion of people living in deprived areas reported putting off a visit to see the GP because of inconvenient hours. Similarly, a significantly higher proportion of people living in deprived areas felt like making a complaint about staff - but had not actually done so.
Also, rates of immunisation, and screening for cervical and breast cancer, are significantly lower in people from more deprived areas - areas where cancer mortality rates are highest. The quality of treatment in general practice for people with chronic diseases such as asthma has been shown to be inadequate, with significantly higher admission rates to hospital for these conditions from deprived areas. The NHS Plan aims to tackle avoidable health inequalities - partly through performance management to improve poor quality services and reduce variation in service provision.
The existing NHS resource allocation formula currently under review links resources to identified need and the interim health inequalities adjustment is an attempt to target more resources to areas of high health inequality.
However, if the NHS is to tackle health inequalities from poor life chances it will need to target deprived areas in new ways - such as accelerated access to secondary care surgery. A market economy in medical care leads to a number of wasteful trends that are acknowledged problems in the United States.
Hospital admission rates are inflated to make patients eligible for insurance benefit, and, according to Fry[34] :. In such circumstances hospital administrators are encouraged to use public relations officers and other means of self-advertisement….
Even small hospitals of beds may consider such features as necessities. And though these are the more obvious defects of substituting profit for the normal and direct objectives of medical care, the audit by profit has another and much more serious fault; it concentrates all our attention on tactical efficiency, while ignoring the need for strategic social decisions.
A large advertising agency may be highly efficient and profitable, but is this a measure of its socially useful work? All these trends of argument are gathered together in the report of the B. It states its view with a boldness that may account for its rather guarded reception by the General Medical Services Committee of the B. The only sacrifice that would have to be made would be the concept of equality within the National Health Service.
In fact, absolute equality could never be achieved under any system of medical care, education or other essential service to the community. The motives for suggesting otherwise are political and ignore human factors. The panel overlooks the fact that absolute correctness of diagnosis or absolute relief of suffering are also unattainable under any system of medical care; perhaps the only absolute that can be truly attained is the blindness of those who do not wish to see, and the human factor we should cease to ignore is the opposition of every privileged group to the loss of its privilege.
In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings, and suffer recurrent crises in the availability of beds and replacement staff.
These trends can be summed up as the inverse care law: that the availability of good medical care tends to vary inversely with the need of the population served.
If the N. If our health services had evolved as a free market, or even on a fee-for-item-of-service basis prepaid by private insurance, the law would have operated much more completely than it does; our situation might approximate to that in the United States,[36] with the added disadvantage of smaller national wealth. The force that creates and maintains the inverse care law is the operation of the market, and its cultural and ideological superstructure which has permeated the thought and directed the ambitions of our profession during all of its modern history.
I am grateful to Prof. Hammond, librarian of the Royal College of General Practitioners; and to the clerks of the Glamorgan and Monmouthshire Executive Councils for the National Health Service for data on recruitment of general practitioners in their areas. Political and Economic Planning London London The Doctor, his Patient and the Illness. Lancet , ii, RCGP reports from general practice no 12 January Practnrs, , suppl.
Uses of Epidemiology. The genesis of the British National Health Service. Oxford Health through choice. Hobart paper no 14, Institute of Economic Affairs, London Med J.
BMA, London, Fabian Society, London, The Long Revolution. Medicine in three Societies. Aylesbury, Some of the arguments in this paper were made earlier by Henry Sigerist. A Reappraisal of the Inverse Care Law This site uses Akismet to reduce spam. Learn how your comment data is processed. Chapter 1: Introduction. Chapter 2: Literature Review. Chapter 3: Methodology. Chapter 5: Discussion. Chapter 6: Conclusion and Bibliography. Enter your email address to subscribe to this blog and receive notifications of new posts by email.
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February 27, The Inverse Care Law. Interpreting the Evidence The existence of large social and geographical inequalities in mortality and morbidity in Britain is known and not all of them are diminishing. Selective Redistribution of Care Given the large social inequalities of mortality and morbidity that undoubtedly existed before the war and the equally large differences in the quality and accessibility of medical resources to deal with them, it was clearly not enough simply to improve care for everyone:some selective redistribution was necessary, and some has taken place.
What Should Be Done? Return to the Market? The Inverse Care Law In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support, and inherit more clinically ineffective traditions of consultation, than in the healthiest areas; and hospital doctors shoulder heavier case-loads with less staff and equipment, more obsolete buildings, and suffer recurrent crises in the availability of beds and replacement staff.
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