Responses to the inverse care law in general practice in Scotland over the past 20 years: a mixed methods study

Context: 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’. Recent evidence has demonstrated the persistence of the ICL in UK general practice, with fewer GPs, less funding and poorer consultation quality in more deprived areas.

Objectives:

1. to synthesise interventions addressing the inverse care law in Scotland,

2. to review evidence of the impact and sustainability of these interventions,

3. to integrate these findings with qualitative interviews with key stakeholders.

Study Design and Analysis: Mixed methods study involving:

1. Systematic scoping review

2. Reflexive Thematic Analysis (RTA) of stakeholder interviews

Setting or Dataset: 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.

Population studied: Key stakeholders were from four professional groups: Deep End GPs (N=5); Academics (N=2); Public Health Specialists (N=7), and Third Sector Organisation Leads (N=3).

Intervention: Any intervention which aimed to increase the volume, quality, or consistency of general practice in deprived areas.

Results: There were 72 included papers (32 papers from the database search and 40 from the grey literature) reporting on 24 interventions. 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.

Four main themes from qualitative interviews were used to structure the synthesis of findings: Context and Manifestations of the Inverse Care Law; Initiatives to tackle the ICL; Impact of the Scottish Deep End Project; and Recommendations for policy and practice.

Conclusions: This research provides further evidence of the persistence of the ICL in general practice in the UK, replicating findings from England. Recommendations to improve the volume and quality of care in deprived areas are widely relevant.