The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland

Abstract

PURPOSEThe inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates.METHODS A questionnaire study was carried out on 3,044 National Health Service (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affl uent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health variables, and a range of factors relating to quality of care. RESULTSCompared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more longterm illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was signifi cantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychosocial), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation. CONCLUSIONSThe increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities. 2007;5:503-510. DOI: 10.1370/afm.778. Ann Fam Med INTRODUCTIONS cotland has the lowest life expectancy for women in Western Europe and the second lowest for men, with a widening gap between the health of the rich and the poor.1 Twenty-one percent of the population in poorer areas have limiting long-term illnesses or disabilities, compared with only 8.5% in affl uent areas. 1 The bulk of health care in Scotland, as in the rest of the United Kingdom, is delivered through primary care, with fully trained family physicians-general practitioners (GPs)-practice nurses, and other allied health professionals accounting for almost 90% of the activity of the National Health Service (NHS). Clinical encounters are free at the point of use and accessible by 100% of the population. Since the inception of the NHS in 1948, however, the provision of primary care services has not been closely related to health needs in more socioeconomically deprived areas. The mismatch of need and supply has been termed the inverse care law, 2,3 which states that "the provision of good medical care tends to vary inversely with 504INV ER SE C A R E L AW the need for it in the population served." In Scotland, despite the steep gradient in need, the distribution of GPs remains fl at across socioeconomic indices. 4 Although inequalities in health and health care are well recognized, [5][6][7] there is a...

General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland—A pilot prospective study using structural equation modeling

“…The confirmatory factor analysis of the CARE measure confirms similar findings on the robust internal structure of this measure reported previously in primary and secondary care settings [9,18,36,37]. The CFA results are essentially also the same as those of the German translation of the CARE measure, which was tested with cancer patients in secondary care [38].…”

“…The importance of physician empathy for patient enablement also confirms previous work in primary and secondary care [11][12][13][14][15]18,21]. The relationship between enablement at consultation and health outcomes at 1 month is a new finding in primary care, though similar relationships have been suggested in secondary care and other settings [13][14][15]18].…”

“…The relationship between enablement at consultation and health outcomes at 1 month is a new finding in primary care, though similar relationships have been suggested in secondary care and other settings [13][14][15]18]. Direct effects of empathy on outcomes have also been reported in the literature [6,13,39] and there is a growing body of evidence linking certain aspects of patient-centred consulting with improved health outcomes [40].…”

“…Direct effects of empathy on outcomes have also been reported in the literature [6,13,39] and there is a growing body of evidence linking certain aspects of patient-centred consulting with improved health outcomes [40]. We have recently postulated an effect model to explain how different aspects of physician empathy may influence different outcomes [18].…”

“…GPs have more problems to deal with in a shorter period of time and report higher stress levels in consultations compared with those working in more affluent areas [4,18]. As there is currently limited empirical evidence on the relationship between empathy, enablement and health outcomes in primary care, the purpose of the present investigation was to explore: (a) the direct effect of patient-reported GP empathy on patient enablement at consultation (b) the indirect effect of patient-reported GP empathy at consultation on patient-rated health outcomes at 1 month post-consultation.…”