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What is the inverse care law?
The inverse care law was first described by Julian Tudor Hart in 1971. It states that "the availability of good medical care tends to vary inversely with the need for it in the population served."
Access to services has also been considered to be affected by the inverse care law. Those who need healthcare least use the services more, and more effectively, than those with the greatest need. This can be seen in both health promotion and the treatment of illness and disease.
What is distributive justice?
The four main principles of medical ethics are respect for autonomy, beneficence, non-maleficence and justice. Obligations of justice may be further subdivided into:
- Distributive justice - the fair distribution of healthcare resources (which may be scarce)
- Rights-based justice - the respect for people's rights
- Legal justice - the respect for morally acceptable laws
Equality underpins distributive justice. An individual's right to healthcare resources should not be affected by who they are, including their age, sex, quality of life, socioeconomic status and race. The rich and the poor should be treated as equals in terms of healthcare provision.
Healthcare resources should ideally be targeted towards minimising loss of health and maximising health gain. In an ideal world, sufficient healthcare would be provided to all who need it. However, this is not always possible and healthcare resources should then be distributed in relation to their need within a society that has equal access to healthcare. The maximum benefit possible should be gained from these resources. The people who are providing these resources (in the UK, taxpayers or people enrolled in private healthcare schemes) should also be considered.
To what extent does the inverse care law apply today?
The National Health Service was established in 1948 to address the inequality in healthcare services. It was set up as a service that was free at the point of use, that was responsive to local needs and that had a good geographical spread of services. The idea was that everyone receive the same high standard of care. This potentially meant that a wide range of healthcare services would become available to people who previously could not afford them.
However, some feel that inequalities in healthcare services still exist. Recent studies and research have also shown that the inverse care law is still apparent today.
The Independent inquiry into inequalities in health by Sir Donald Acheson in 1998 showed that premature mortality and limiting long-term illness were both strongly associated with deprivation in the UK.
One study looked at the effect of socioeconomic deprivation on waiting times for cardiac surgery. Deprived patients were more likely to develop coronary heart disease but less likely to be investigated and undergo surgery. It has also been shown that children growing up in socioeconomic deprivation have poorer health than their peers in higher social classes.[7, 8] Another study has shown that increasing socioeconomic deprivation is associated with a higher prevalence of psychological distress but shorter consultation lengths (ie a lack of primary care resources).
In present day general practice, quality and outcomes framework payments to practices are based on the care delivered to patients. A recent study looked at deprivation and the quality of primary care services and found that the quality of care delivered falls with increasing deprivation (examples were in glycaemic control monitoring in diabetes and in influenza immunisation uptake). It could be argued that this suggests that additional work is required in deprived areas and supports the fact that the inverse care law still applies.
Other reports are that good medical care is more readily available today in deprived areas but raises the question of who accesses the services that are there. An article published in 2004 showed the relationship between access to services and health. It found that people aged 0-64 living closer to general practices had higher mortality and limiting long-term illness rates (i.e despite the fact that they lived close to medical care they still had adverse health outcomes). This would refute that the inverse care law still exists to some extent as it would seem that good medical care is available in these deprived areas. However, it may also suggest that even though the availability is there, those who need the services most still aren't using them effectively. The latter supporting the fact that access to services is also affected by the inverse care law (those with the greatest need use healthcare least).
Another paper looked at the relationship between social deprivation and geographical proximity to general practices and found that geographical proximity was greater in more deprived areas, ie availability of services was good in areas of need and refuting the inverse care law. However, this paper also states that it must not be forgotten that, just because someone lives close to a healthcare service, does not necessarily mean that they will access the service or that the service provision will be of good quality.
Another recent study looked at quality of care indicators in the quality and outcomes framework for coronary heart disease (CHD) in general practices. It found that CHD prevalence was associated with deprivation in that area but that there was no evidence of socioeconomic inequality in CHD care.
Distributive justice in the modern-day NHS
Ethics and morals govern that everybody should have an equal opportunity to benefit from a public healthcare system. The chance of them benefitting, the quality of the benefit or the length of lifetime left to enjoy the benefit should not affect the allocation of resources.
However, rationing of healthcare resources is a fact of life in most healthcare systems. Is it fair that if someone with a terminal illness has a very expensive treatment which means that resources are taken away from other areas where they could potentially benefit a greater number of people? There are no simple answers.
National Service Frameworks (NSFs) have been established to act as long-term strategies for improving specific areas of healthcare. Measurable goals are set within specific time frames. Issues such as distributive justice are addressed by these frameworks. For example, aims for the NSF for Coronary Heart Disease include to increase the number of revascularisation procedures and to reduce inequalities in access to care.
The National Institute for Health and Clinical Excellence has also been set up to provide national guidance on promoting good health and preventing and treating ill health. The standard guidelines that they produce using evidence based medicine should help as an aid to distributive justice and equity and efficiency within the healthcare system.
Further reading and references
Community engagement: improving health and wellbeing and reducing health inequalities; NICE Guidelines (March 2016)
Hart JT; The inverse care law. Lancet. 1971 Feb 271(7696):405-12.
The health divide. London: Penguin, 1988
Gillon R; Medical ethics: four principles plus attention to scope. BMJ. 1994 Jul 16309(6948):184-8.
Harris J; The rationing debate: Maximising the health of the whole community. The case against: what the principal objective of the NHS should really be. BMJ. 1997 Mar 1314(7081):669-72.
Pell JP, Pell AC, Norrie J, et al; Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study. BMJ. 2000 Jan 1320(7226):15-8.
Poverty and child health. Oxford: Radford Medical Press, 1996
Webb E; Children and the inverse care law. BMJ. 1998 May 23316(7144):1588-91.
Stirling AM, Wilson P, McConnachie A; Deprivation, psychological distress, and consultation length in general practice. Br J Gen Pract. 2001 Jun51(467):456-60.
McLean G, Sutton M, Guthrie B; Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework. J Epidemiol Community Health. 2006 Nov60(11):917-22.
Jordan H, Roderick P, Martin D; The Index of Multiple Deprivation 2000 and accessibility effects on health. J Epidemiol Community Health. 2004 Mar58(3):250-7.
Adams J, White M; Socio-economic deprivation is associated with increased proximity to general practices in England: an ecological analysis. J Public Health (Oxf). 2005 Mar27(1):80-1. Epub 2005 Jan 6.
Strong M, Maheswaran R, Radford J; Socioeconomic deprivation, coronary heart disease prevalence and quality of care: a practice-level analysis in Rotherham using data from the new UK general practitioner Quality and Outcomes Framework. J Public Health (Oxf). 2006 Mar28(1):39-42. Epub 2006 Jan 25.
Harris J; Justice and equal opportunities in health care. Bioethics. 1999 Oct13(5):392-404.
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