The term "inverse care law" was first coined in the United Kingdom in 1971 by a GP by the name of Julian Tudor Hart. It describes how the people who are sickest are least likely to receive an appropriate health service. It is a common expression, but what does it mean in practice? If members look at the coloured diagram I circulated, it is about what happens when one distributes services according to numbers, not according to need.
The first drawing represents an average or affluent area versus a disadvantaged area with 1,000 people in it. There is one health service which could be provided by a GP, a public health nurse, an occupational therapist, a hospital and an ultra-sound machine. Within the 1,000 people a certain number will be chronically ill or are going to die. With the same distribution of resources in a disadvantaged area, as Professor Smith outlined, the mortality rate is much higher, as is multimorbidity. Within the 1,000 people one has twice as many sick people and people who are going to die, but one still has only one GP, one public health nurse, one hospital and one ultra-sound machine. Therefore, one is effectively offering these patients half the service by distributing resources flatly according to numbers across the system.
The diagram illustrates an extreme version of this and what happens in certain areas of disadvantage where numbers are not even equally distributed. The national average for GPs to patients is one to 1,600, but in north-west Dublin where I practise it is one GP to 3,600 patients. Within a given population, a GP has twice as many patients, twice as many of whom are sick or who are going to die. That is a really extreme version.
There are many reasons for it and we are going to outline the nature of practice in these areas which leads to these problems.
One of the core reasons relates to the way the general medical services, GMS, scheme is funded according to capitation. This means we get a fixed rate for a patient for the year, regardless of the number visits, regardless of whether it is one, ten or 100 visits a year or whether the visit lasts for five, ten or 50 minutes. The only variable within the GMS scheme payment structure is age. Research from the United Kingdom shows that a 50 year old living in one of the most deprived areas will consult at the same rate as a 70 year old living in one of the most affluent, and yet the fees are far lower. On the periphery of the big cities, the average population is far younger and, as a result, in certain practices the average GMS payment per year is actually far lower than the national average. In north-west Dublin, for example, it is 74% of the national average but morbidity and mortality is far higher in younger patients in these areas.
Unfortunately, the inverse care law pervades the system. It is not only prevalent in primary care - although it is obvious to those of us in primary care - it is also a feature of many other services that our patients need, especially diagnostics. There is a good deal of variation within the public system in essential tests, such as ultrasound and colonoscopy tests. We need to carry out these tests for our patients to identify cancers early and so on. There is extraordinary variation, however. A great deal of our time is spent trying to access services for patients, especially locally in our communities. This applies to all primary care services. Since they are distributed according to number, there are not nearly enough of them for the needs of the population. Critical support services for vulnerable families include child and adolescent mental health services, child psychology, occupational therapy, child protection and access to social workers. The supply of these services is much slower in the areas in question, yet the needs are so much higher. The delays compound the existing problems for patients and this adds to the burden for those of us trying to care for them. We have to contain them, hold them safe and manage considerable risk while trying to access the services that our patients have such difficulty getting. Moreover, there is no safety valve. They cannot go instead and see someone privately or get a private MRI or ultrasound scan.
I will briefly describe a typical morning in my practice. It is typical of many practices throughout the country. The patient I will talk about is a woman called Catherine who is 54 years of age with multi-morbidity. This is very common. General practice is all about multi-morbidity now but in these areas it comes far younger and it is complicated by psycho-social problems. Catherine is 54 years old. She has a background of chronic lung disease, diabetes and eczema. She is struggling with a 13 year old daughter who has behavioural problems. In the background, she is still smoking. I know her diabetes is not well controlled because I checked her blood levels on her previous visit. Her smear test has been overdue for a year. My system reminds me of this, as does my nurse. Catherine has missed a couple of appointments for the test. She is down today with a chest infection and a flare-up of her eczema. She comes in, sits down and we start dealing with it. As is typical in our practice, unfortunately, the telephone rings. Normally, we would never take calls during a consultation but this is an urgent call from a child protection social worker who needs me to drop everything because she is going to court later that day for a care order in respect of a vulnerable child. I am the only professional who has seen the mother of that child in the past week. They want a letter from me about my opinion on the capacity of the mother to care for her child. Catherine has to leave then because I have to have that conversation, write the letter, go to reception with the facsimile and then come back. Then, I call Catherine back in. She goes on to tell me that she has not been sleeping for the past month because her niece died after an illness. She then tells me her daughter has just been suspended from school, which is the thing worrying her most today. She needs a letter for clothing and she has to have it today. It is urgent because she does not have the money to get runners for her daughter. Meanwhile, the waiting room is full of many more patients like Catherine, all waiting to come in to have these things dealt with. In any event, we work our way through the chest infection and eczema. We look at the diabetes but the diabetes was very much impacted upon by the illness and death of her niece. It caused her eating to go all over the place. We agree not to change the medication and to wait to see if things would settle down. We talk about her bereavement and other bereavements that she has had as well as her lack of sleep. We talk at length about her 13 year old daughter who has been suspended from school. She missed her children and adolescent mental health services appointment because of the funeral. As a result, I have to write a letter later to get her back into that system. I have to write a letter for the school as well. We consider talking about her smoking but she is really upset today so I do not think it is a good day for it. We arrange the prescriptions, her next appointment and the letter for the clothing, which is critical for her. Then, when we have done all that, we remember that she still has not had her smear test. I put it to her that we need to do the smear test today but she says she is simply is not in the humour for it. I am not in the humour for it either because the waiting room is packed and so much has been going on.
Ironically, these patients are often called "hard to reach" by services. CervicalCheck is a brilliant cervical screening programme. The uptake is far lower in our areas even though the mortality rate relating to cervical cancer is higher there. These people are hard to reach for screening programmes and many other things but they are not hard to reach for us. They come to our practices every day of the week. However, their acute mental health, social and physical problems are so overwhelming that we do not get to look after their chronic illnesses or undertake cancer prevention or screening. These are all the things we could do and they would make such a difference to them now as well as down the track. They would prevent these patients from getting sick and presenting later on with cancers, like they do. They do not simply need more GP time, they need more administrative time and a great deal of support time. Our secretaries spend a good deal of their days telephoning and texting people about their appointments with us and the hospitals. That is, if we know when those appointments are coming up - we do not always know. We need a good deal of time to liaise with our primary care colleagues. Unlike some parts of the country, primary care teams function very well in our areas because we need them and our patients need them. We need to spend a good deal of time liaising with them. They are under-resourced and understaffed but they are absolutely fantastic professionals. Public health nurses in particular are an incredible help. They are the backbone of the health service. They do not get much notice but they are very important. I have tried to explain a typical morning and how it is that acute health and social problems act as a serious barrier to chronic disease management and cancer screening and prevention. Even when our patients have a general practitioner, they still do not have appropriate access to proper care.
