Inverse Care Law and Distributive Justice

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."¹

Access to services has also been considered to be affected by the inverse care law. Those who need health care least use the services more, and more effectively, than those with the greatest need.² This can be seen in both health promotion and the treatment of illness and disease.

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 laws³

Equality underpins distributive justice. An individual's right to health care 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 health care provision.⁴

Health care resources should ideally be targeted towards minimising the loss of health and maximising health gain. In an ideal world, sufficient health care would be provided to all who need it. However, this is not always possible and health care resources should then be distributed in relation to their need within a society that has equal access to health care. 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 health care schemes) should also be considered.³

The National Health Service was established in 1948 to address the inequality in health care 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 received the same high standard of care. This potentially meant that a wide range of health care services would become available to people who previously could not afford them.

However, some feel that inequalities in health care 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.⁵

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.⁶ 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 (i.e. a lack of primary care resources).⁹

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 influenza immunisation uptake). This suggests that additional work is required in deprived areas and supports the inverse care law.¹⁰

However, other reports are that good medical care is more readily available today. An article published in 2004 showing the relationship between access to services and health found that people aged 0-64 living closer to general practices had higher mortality and limiting long term illness rates.¹¹ This is the opposite of what the inverse care law suggests. Have we taken note of the inverse care law and do we now provide better access to those who most need health care?¹²

Another paper looking at the relationship between social deprivation and geographical proximity to general practices found that geographical proximity was greater in more deprived areas. This paper also states that it must not be forgotten that just because someone lives close to a health care service does not necessarily mean that they will access the service or that the service provision will be of good quality.¹³

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.¹⁴

Ethics and morals govern that everybody should have an equal opportunity to benefit from a public health care 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?¹⁵ 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.