What interventions have addressed the Inverse Care Law in general practice in Scotland over the last 20 years? A systematic scoping review

Problem

In 1971, Julian Tudor Hart defined the inverse care law (ICL) as: “the availability of good medical care tends to vary inversely with the need for it in the population served [1]. Recent evidence has demonstrated the persistence of the ICL in general practice in the UK, with fewer GPs, less funding and poorer consultation quality in more deprived areas [2]. The aims of this study were: 1) to map out interventions and the rationale behind them, and 2) to review evidence of the impact and sustainability of these interventions – what has worked, for whom and why?

Approach

Systematic scoping review. We searched EMBASE, Web of Science, MEDLINE, CINAHL, Cochrane and BASE from 2000 to current, to retrieve papers describing interventions or policies which aimed to address the inverse care law in general practice in Scotland. In addition, we performed a systematic grey literature search, of government, NHS and third sector websites. All papers were double screened for inclusion. We included quantitative and qualitative studies. Our primary outcome was any intervention or policy in General Practice which aimed to address health inequalities. Conference proceedings, poster abstracts and discussion papers were excluded. We did not include other aspects of primary care such as dental or pharmacy.

Findings

There were 72 included papers (32 papers from the database search and 40 from the grey literature) reporting on 24 interventions. Preliminary findings demonstrate a range of intervention types addressing a) increasing supply of health care in deprived areas (e.g. staffing, financial resources), b) the quality of care (e.g. training, peer support, etc.), and/or c) the organisation of care (e.g. multi-disciplinary team (MDT) meetings, referral pathways, improving access, etc.) Six interventions accounted for 43% of all included papers: the link worker programme (n=16), Keep Well (n=7), welfare advice services embedded in practices (n=6), the CARE Plus study (n=4), the Govan SHIP (n=4), and the Scottish Deep End Project (n=4). Approximately one third of included papers are qualitative studies. Evidence of impact and sustainability was variable, but often absent.

Consequences

This research provides further evidence of the persistence of the inverse care law in general practice in Scotland, replicating findings from similar work (also funded by the Health Foundation) in England. Recommendations arising from this work will be relevant to all levels of General Practice, from local service delivery national policy making. References1) Hart JT. The inverse care law. Lancet. 1971 Feb 27;1(7696):405-12. doi: 10.1016/s0140-6736(71)92410-x. PMID: 4100731.2) McLean G, Guthrie B, Mercer SW, et al. General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. Br J Gen Pract. 2015; 65: e799-e805