Health inequalities: the ideas of Julian Tudor Hart
Julian Tudor Hart was born in 1927, graduated from Cambridge in 1952 and worked as a GP in West Wales for 30 years. He became involved in epidemiological research, with Richard Doll and Archie Cochrane. He has authored many research papers and books on hypertension management, organisation of healthcare and the NHS. He was the inaugural winner of the RCGP Discovery prize in 2006. When nominating him, Professor Graham Watt said:
"His ideas and example pervade modern general practice and remain at the cutting edge of thinking and practice concerning health improvement in primary care. His work on hypertension showed how high-quality records, teamwork and audit are the keys to health improvement. His lifelong commitment to the daily tasks of general practice has always given his work and views a salience and credibility with fellow general practitioners. Julian Tudor Hart has been and will remain an inspiration to health practitioners and the communities they serve."
He is probably best known for The Inverse Care Law. This was first published in the Lancet in 1971 and takes its name from a pun on a law of physics (the inverse square law) describing the strength of gravitational fields. The Inverse Care Law states that: "The availability of good medical care tends to vary inversely with the need for the population served. This Inverse Care Law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced." Or, as Frank Dobson put it when he was Health Minister: "Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you'll die sooner because you're badly off."
Tudor Hart framed his thoughts in large-scale socio-economic terms but it is now widely recognised that health inequalities can occur on many levels and may be due to social, geographical, biological or other factors. These differences have a huge impact, because they result in people who are worst off experiencing poorer health and shorter lives.
In England, the cost of treating illness and disease arising from health inequalities has been estimated at £5.5 billion per year. (1) In terms of the working-age population, it leads to productivity losses to industry of between £31-33 billion each year.
Three out of four families that receive income support spend a seventh of their disposable income on cigarettes, so interventions that focus on reducing levels of smoking can make a real difference to health inequalities. Tackling tobacco use alone would save local services millions a year. For example, £160 million in a city such as Liverpool, where there are high levels of deprivation and inequality, or £61 million in a deprived London borough such as Newham, or £24 million in a less deprived local authority such as South Oxfordshire District Council. (1)
Public health campaigns hope to tackle such large-scale problems and the latest NICE guidelines (March 2016) set out plans to try to harness local knowledge and work with communities to achieve these goals. (2)
On a practice level, just having awareness of inequalities may be the first step to redressing the balance. For example, the late Helen Lester was a passionate RCGP champion for mental health. People with serious mental health problems are more likely to suffer from physical health problems, such as hypertension, coronary heart disease and diabetes and are therefore more likely to die 15 to 20 years earlier than the rest of the population. They are also less likely to present for annual or screening checks when invited. Could your receptionists routinely book these patients for a longer consultation, so you can screen them opportunistically? Are you able to signpost to your local services beyond healthcare, in particular social care, housing and benefits? The traditional primary care gatekeeper role is often less appropriate than a navigator for these patients, as 90% or more generally stay within primary care. We are perfectly placed to make a difference, as Julian Tudor Hart knows very well.
1. Health inequalities and population health; National Institute for Health and Care Excellence, October 2012.
2. Community engagement: improving health and wellbeing and reducing health inequalities; National Institute for Health and Care Excellence, March 2016.