Responses to the inverse care law in Scotland over the past 20 years: a qualitative study.

Problem

In 1971, Julian Tudor Hart defined the inverse care law as: ‘the availability of good medical care tends to vary inversely with the need for it in the population served’. Several policies and interventions have sought to address the inverse care law in general practice in Scotland by improving the volume and quality of care in areas of deprivation, with limited evidence of impact. The aim of this study is to explore the views and experiences of key stakeholders about responses to the inverse care law in general practice in Scotland. The findings of this research will help to inform future policy and practice responses.

Approach

The methodology used to analyse the interviews is Reflexive Thematic Analysis (RTA) (Braun & Clarke, 2006). In RTA, themes are not pre-defined with the purpose of finding codes. Instead, themes are identified via the organisation of codes around a ‘central organising concept’ (Braun & Clarke, 2006; 2019). In the case of the present study, the central organising concept was the Inverse Care Law (Tudor Hart, 1971). The aim was to recruit between 15 and 20 participants for the semi-structured interviews. Of the 24 participants initially contacted, 17 agreed to participate. Interviews took place between May and December 2022. The participants were key stakeholders from four professional groups: Deep End GPs (N=5); Academics (N=2); Public Health Specialists (N=7), and Third Sector Organisation Leads (N=3). A flexible approach to sampling was maintained and recruitment occurred through snowball sampling and existing links within the research team. Open ended questions were used to allow for the in-depth exploration of issues pertaining to the study’s overall aim.

Findings

Four main themes were identified. The main themes (with sub-themes in brackets) were: Context and Manifestations of the Inverse Care Law (Social determinants of health, Wider policy context, GP contract); Initiatives to tackle the ICL (Local, National and Regional level interventions, and Issues around sustainability and scaling up of these interventions); Impact of the Scottish Deep End Project (Workforce, Education, Advocacy, Research); and Recommendations (Trauma informed care, Proportionate universalism and Funding of primary care).

Consequences

The results shed a light on several aspects of the Inverse Care Law and how it has operated in Scotland over the past 20 years. The inclusion of key stakeholders from Public Health, Research, Third Sector and Deep End practices enhances the trustworthiness and validity of the results illustrated. The findings have important implications that include informing future policy, interventions, and approaches to address the inverse care law in Scotland.