The inverse care law: how where you live is a matter of life and death
Edel McGinnity, from Dublin, Ireland, spoke about the role that health systems might play in inequality.
Inequality in health outcomes is well documented across all health systems. This is particularly so for cancer mortality. What has not been studied so intensely is the role that health systems themselves might play in this.
The inverse care law was suggested 30 years ago by Julian Tudor Hart in a paper for the medical journal The Lancet. It described the relationship between the need for health care and its actual utilisation.1 In other words, he argued that those who most need medical care are least likely to receive it.
Patients living in the most deprived areas
Inequalities in health arise not only from variations in access to health services, but also from variations in the quality of health care from area to area. The mechanisms by which socio-economic status influences health status are complex and varied. They are underpinned by many factors: wealth, lifestyle, genetic and environmental considerations. Extensive studies of social disadvantage and health suggest that patients living in the most deprived areas:
- have lower life expectancy and higher mortality at all ages
- present later with cancer and are twice as likely to die from it
- have higher rates of chronic conditions with more than twice the likelihood of having heart disease and stroke and higher prevalence of multimorbidity
- suffer higher rates of multimorbidity occuring 10-15 years earlier and complicated by psychosocial problems
- use GPs working with approximately 40% more patients with multimorbidity
- are more than twice as likely to have a combination of physical and mental health problems, with rates of 113/1000 patients compared to 52/1000 for practices working in the most affluent areas.
A 2015 cross-sectional study involving 956 general practices in Scotland2 looked at how the funding model for general practice may actually be perpetuating health inequalities rather than reducing them. They estimated the numbers of patients with multimorbidity, the numbers of consultations per 1000 patients, and payments to practices per patient (see figure) and plotted them against deprivation decile at practice level:
They found that levels of multimorbidity as well as mortality rose with practice deprivation. There was no evidence that general practice funding matched clinical need. They also reported that general practice was unlikely to mitigate health inequalities, and may increase them.
This represents the concept of resourcing healthcare according to numbers without regard for the varying needs of the populations. This is common in systems that describe “universal” health care access. The flat surface of the pool represents the “equal” funding; underneath the surface, the health needs vary widely.
Inverting the previous graph of mortality/morbidity illustrates this eloquently:
Distribution of resources
Another way of looking at the inverse care law is to consider what happens when you distribute resources (and in the case of primary care, resources means personnel) simply according to numbers, without regard for need.
This illustration shows how, if you have a professional or a service (a GP, a public health nurse, an ultrasound machine or an oncology unit) for a set number of people – say 1000, in two areas, you will have very different scenarios. In an average or affluent area within those 1000 people you will have a specific mortality and a certain number will be sick.
In the most disadvantaged area however, within the same 1000 people there will be twice the mortality, twice the morbidity, yet you still have only one of whatever health professional or service we are discussing:
You are effectively offering these very-high-needs populations half the service that is being provided in areas of less disadvantage.
How does this translate into the day to day experience of providing healthcare?
Here is an example of a typical case seen in my practice – early onset of multimorbidity complicated by psychosocial problems, with all the lost opportunities for prevention and screening:
Catherine, age 54, has a background history of chronic lung disease, diabetes and eczema. She has a 13-year-old daughter with behaviour problems. She is still smoking, her diabetes is not controlled and her smear is overdue for a year (missed appointments). She comes to visit with a chest infection and a flare of eczema, and needs a letter to support her application for a clothing allowance. She is not sleeping because her niece died three weeks ago and her daughter has been suspended from school. She is not eating well and has lost some weight from all the stress. The GP sorts the chest infection (deciding that this is not a good day to discuss smoking) and the eczema.
The GP also considers the diabetes medications, but realises Catherine was eating very badly around the time of the funeral. They discuss her sleep and bereavement. Catherine talks at length about her daughter (who has missed a psychiatry appointment) and the GP undertakes to write to the psychiatry service and the school after the surgery. The GP then does the repeat prescription and makes a follow up appointment and then remembers the smear, which neither patient nor GP feels like doing by then. Given her weight loss and cough she probably also needs a chest X Ray, but that gets overlooked with everything else.
A GP practicing in the “Deep End” could have very many of such patients in an average day.
These patients are often called ‘hard to reach’ – for example the uptake of cervical screening is lower in these areas – but actually they have frequent contact with the practice, so we are ideal to catch them. Acute health and social problems act as serious barriers to chronic disease management, cancer screening and prevention.
When you meet a patient in your oncology clinic who has presented late with their cancer (and possibly reports multiple visits to their GP) this is the kind of scenario that may have unfolded in those visits.
Even when the GP suspects cancer, there are many barriers to effective care. Diagnostic tests are often more difficult to get in these areas because of the demands on the service.
The hospital systems often seem to be set up to suit the hospital and not our patients, many of whom have problems with literacy (as well as health literacy). They move house often and change phone numbers with startling frequency. A simple thing like our staff calling to remind people about hospital appointments can make a huge difference, but this is very resource intensive.
Often an acute social crisis will take priority over a hospital appointment (being homeless, going to court, for example) but many hospitals now discharge people if they miss just one appointment.
How can we start to fix it?
There are many innovative ways of supporting practices and patients in the “Deep End” to care better for the patients who are the most likely to die. The Deep End website offers many resources outlining these:
The most fundamental requirement is for all health systems to distribute their resources according to the needs of the populations they serve, rather than according to numbers.