How much has really changed 50 years on from seminal article on health inequality?

Professor Peter Saul, Joint-Chair RCGP Cymru Wales

“The availability of good medical care tends to vary inversely with the need of the population served”.

It is a sentence which could easily fit into the growing evidence base looking at how the impact of Covid-19 has spotlighted health inequalities in Britain with differential and more profound effects on disadvantaged communities.

But this is no contemporary statement; it harks back 50 years to the conclusion of Dr Julian Tudor Hart’s seminal article on this general principle, known as Inverse Care Law published in the Lancet medical journal in 1971. The article was highly influential and the term has become widely adopted.

Dr Tudor Hart, who worked for 30 years as a general practitioner in Glyncorrwg, Glamorgan, later paraphrased his argument: “To the extent that health care becomes a commodity it becomes distributed just like champagne. That is rich people get lots of it. Poor people don’t get any of it.”

As we mark this anniversary, one wonders ‘how much has changed?’  In so many aspects of clinical care Dr Tudor Hart’s findings resonate with the experience of patients and clinicians in general practice today.

For sure, over the last half-century many efforts have been made to respond to the challenge of health inequality, but we need to accept that the essence of the Inverse Care Law still applies, those in leafy suburbs almost everywhere have access to quantitatively and qualitatively better health resources.

Dr Tudor Hart went further and warned that the “Inverse Care Law operates more completely where medical care is most exposed to market forces”. How does this stack up in today’s environment?

‘Market forces’ 

We only have to look at our wrists to examine a distinctly modern aspect of healthcare in which market forces are very dominant. The emergence of health and wellbeing digital apps is a welcome innovation with potentially exciting health benefits.

Such devices can prompt engagement with desirable health activity, they can detect and alert the wearer to abnormal heart rhythms and measure oxygen levels in the blood, have a fall and a message can be flashed to the ambulance service.

A range of other wearable technology such as glucose monitors is already in use, next steps will involve linking information from these devices to care providers such as GPs and I suspect that this will only be the start.

But how do these innovations fit with principles of equality of access to healthcare and an entirely public NHS? Should opportunities to improve health and wellbeing rely on a person being able to afford the latest gadgets, subscriptions and data plans?

The private companies who develop the apps and the kit they run on are there to make a profit.  Profit is going to come from a health-focused affluent group of people, individuals who are, on balance, likely already to be in the healthier segments of the population.

This is a modern example of the market effecting the distribution of healthcare. As Dr Tudor Hart stated, “it was clearly not enough simply to improve care for everyone” and that “some selective redistribution was necessary”.

There is an urgent need to consider how these advancements can be harnessed to benefit those who stand to gain the most from its potential but might be least able to afford to do so.

Then there is the ‘commoditisation’ of our data, information which is of value to the individual, their GP and at a macro level to health economists seeking to plan for future care needs but which now flows through the hands of private companies seeking to profit from it.  How do we gain access in order to help direct responses to public need and prevent potential exploitation of our data?

‘Challenge’ 

A similar challenge presents itself with social prescribing. Non-medicalised prescribing has proven a successful alternative for many patients. It creates a formal way for primary care services to refer patients with social, emotional or practical needs to a variety of non-clinical services.

This helps to empower the patient to have greater agency over their health choices. Yet, to deliver on the ambitions of social prescribing requires the options for referral to be accessible. It is disproportionately more likely that the prescribed activity or class will be available in a more affluent community.

Let’s take the case of encouraging a patient to take up a simple activity such as jogging, what do we need for success?  First of all, time: time away from the kids or perhaps caring, then there is the kit, a social network to keep you company, and a nice route to run, one where you can feel safe. Now imagine how easy engagement is for individuals at either end of the economic and social spectrum.

If Dr Tudor Hart reviewed his paper today, he would need only to examine the effects of Covid-19 on different communities to hear the echoes of his original conclusions ring across the years.  He might look at the impact of new technologies and the relative effects of social prescribing and surmise that the principles he espoused continue to fall on deaf ears.

As we develop our medical science, and as we as clinicians get better at working with our patients, we must keep the values underpinning his original article front and centre of our practice.  To truly succeed in improving care, we need to take our patients with us, and this may mean devoting more time effort and expense to those who are at the margins and are less confident or comfortable in engaging with the health system.

The Royal College of General Practitioners was also referenced in the 1971 article. Dr Tudor Hart complimented the “vigour” of the College in expanding a “well-organised, community-oriented, and self-critical” model of primary care. As we slowly emerge from the tragedy of the pandemic, this College recommits itself to the cause of tackling health inequality.