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The Inverse Care Law: Clinical Primary Care Encounters in Deprived and Affluent Areas of Scotland

General Practice and Primary Care, Division of Community-Based Sciences, University of Glasgow, Glasgow, Scotland

CORRESPONDING AUTHOR: Stewart W. Mercer, MBChB, PhD, General Practice and Primary Care, Division of Community-Based Sciences, University of Glasgow, 1 Horselethill Rd, Glasgow G12 9LX Scotland, sm83z{at}clinmed.gla.ac.uk

PURPOSE The inverse care law states that the availability of good medical care tends to vary inversely with the need for it in the population served, but there is little research on how the inverse care law actually operates.

METHODS A questionnaire study was carried out on 3,044 National Health Service (NHS) patients attending 26 general practitioners (GPs); 16 in poor areas (most deprived) and 10 in affluent areas (least deprived) in the west of Scotland. Data were collected on demographic and socioeconomic factors, health variables, and a range of factors relating to quality of care.

RESULTS Compared with patients in least deprived areas, patients in the most deprived areas had a greater number of psychological problems, more long-term illness, more multimorbidity, and more chronic health problems. Access to care generally took longer, and satisfaction with access was significantly lower in the most deprived areas. Patients in the most deprived areas had more problems to discuss (especially psychosocial), yet clinical encounter length was generally shorter. GP stress was higher and patient enablement was lower in encounters dealing with psychosocial problems in the most deprived areas. Variation in patient enablement between GPs was related to both GP empathy and severity of deprivation.

CONCLUSIONS The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.

Key Words: Poverty • chronic disease • comorbidity • consultation quality • outpatient care • patient-physicians relations • empathy • primary health care

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