The inverse care law

Fifty years ago, a Welsh GP called Julian Tudor Hart coined a phrase “the inverse care law”, which states that people who need services most are often the least likely to get them.

The flipside of this is that some people with less need for healthcare will use it more. This type of inequality exists in many places – some people will be able to buy more clothes than they need whilst others people won’t be able to afford enough to keep them warm. But given that the health service (in the UK at least) is based on a principle of clinical need rather than an ability to pay, this inequality should not exist within the NHS.

As The King’s Fund state: “Although Tudor Hart did not provide hard evidence to support his hypothesis, many others have. There is also plenty of evidence now from routine health service data – such as the NHS performance indicators and from the surveys of NHS patients.

“In areas with high needs, such as inner cities and deprived areas, there tend to be fewer doctors working with higher caseloads and sicker patients. Although GPs are encouraged to work in ‘underdoctored’ areas through a system of incentives, these have not enticed enough GPs to work in the poorest areas.”

The inverse care law can often also be seen when it comes to engaging with people about how to develop and deliver health services. People who are least likely to have received healthcare are also least likely to have a say in how it is developed and designed. Conversely, certain groups of people may be over-represented in discussion and decisions about health service provision. This then leads to services which are better designed for this cohort, at the expense of other communities.

If we really want to design and deliver services that work for everyone, we have to be alert to the inverse care law and work against it. That might well mean focusing our effort on working with groups who have been pushed out or pushed to the edges.

What do you think of the idea of the inverse care law? Have you seen examples of it in practice? What are good ways to mitigate the effects of it, especially around engagement work?