2.3 The inverse care law

The ‘inverse care law’ was suggested by Tudor Hart (1971) to describe the frequently-observed relationship between the need for, and provision of, medical care. Essentially the provision of care is often poorest in the areas where it is most needed. Hart originally saw this phenomenon in the UK in relation to general practitioner services as developing in response to a failure of government to shield the National Health Service from the operation of market forces. Nevertheless, a similar phenomenon is observable in health care systems across the developed and less developed worlds and under a wide range of market-driven and welfare-motivated health care systems. Tied up with recognition of the inverse care law is an underlying assumption that health care services should in fact be distributed fairly, the concept of ‘distributive justice’, or in geographical terms ‘territorial justice’ whereby the provision of health services in each area broadly matches the needs of its population. In reality, measurement of both the need for and delivery of health care in simple terms is problematic but the same relationships have been shown by many studies using numerous different measures. Examples include the paper by Pell et al. (2000) which explores socioeconomic differentials in waiting times for cardiac surgery in the UK and Furler et al. (2002) which examines access to GP services from disadvantaged areas in Australia. Tamburlini (2004) considers aspects of health equality and the inverse care phenomenon in a developing world context.

The potential reasons for the inverse care law are complex. In general terms, higher rates of ill health are associated with poorer social conditions and low income. Populations with greatest need will thus tend to be concentrated in areas of poorer housing and amenities. These will be the least attractive areas to which to recruit and retain medical staff. A particular example in the UK is the provision of GP services which are provided by independent doctors working under contract to local health authorities. In general terms, there has been a tendency for practitioners to group together into larger practices offering a range of increased services, but this is most evident in relatively affluent suburban locations while older, often single-handed, GPs working in poorer premises have remained to a greater degree in the relatively deprived inner city areas. Although GPs are paid primarily by capitation (i.e. in proportion to their numbers of registered patients), throughout the 1990s an explicit system of deprivation payments was used whereby additional financial reward was given to GPs for each patient on their registration lists living in areas identified as deprived (using an index of social deprivation known as the Jarman index). This was a direct policy response to incentivise provision of primary medical care for more deprived populations. Attempts to counter the inverse care law can operate at the level of the entire health care system but will also often require specific spatial targtetting of policies and resources.
 

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