Research ArticleOriginal Research

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

Stewart W. Mercer and Graham C. M. Watt
The Annals of Family Medicine November 2007, 5 (6) 503-510; DOI: https://doi.org/10.1370/afm.778

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Relationship between psychological distress and comorbidity in high-and low-deprivation areas.

  • Figure 2.
    Figure 2.

    Distribution of clinical encounter duration in areas of high-and low-deprivation.

  • Figure 3.
    Figure 3.

    GP stress by clinical encounter duration in areas of high-and low-deprivation.

  • Figure 4.
    Figure 4.

    Patient enablement by clinical encounter duration in complex encounters in areas of high-and low-deprivation.

Tables

  • Table 1.

    Characteristics of Patients Visiting General Practitioners in Poor and Affluent Areas of Scotland

    CharacteristicsMost Deprived Areas n (%)Least Deprived Areas n (%)P Value
    * A measure of psychological distress on the General Health Questionnaire – 12,11 with a score of 4 or more.
    Emotional distress Caseness*652 (41.3)273 (28.6)<.001
    Comorbidity: No. of chronic conditions.008
        0485 (24.7)271 (25.2)
        1491 (25.0)320 (29.7)
        2387 (19.7)223 (20.7)
        3 or more599 (30.5)262 (24.3)
    General health<.001
        Very good206 (11.3)166 (16.1)
        Good471 (25.9)375 (36.5)
        Fair665 (36.6)339 (33.0)
        Bad383 (21.1)122 (11.9)
        Very bad94 (5.2)26 (2.5)
    Long-term illness
        Yes975 (53.7)432 (42.1)<.001
    Job status<.001
        Employed651 (37.9)516 (51.8)
        Unemployed (looking)115 (6.7)36 (3.6)
        Unemployed (unable)434 (25.3)103 (10.3)
        School or full-time equivalent76 (4.4)63 (6.3)
        Retired247 (14.4)209 (21.0)
        Caring for home/family170 (9.9)61 (6.1)
    Home<.001
        Owner occupier732 (40.6)833 (81.3)
        Rented981 (54.2)140 (13.6)
        Other92 (5.1)51 (5.0)
  • Table 2.

    Clinical Encounter Characteristics: Patient Access to a General Practitioner

    CharacteristicsMost Deprived Areas n (%)Least Deprived Areas n (%)P Value
    Scheduled encounter1,612 (83.2)968 (90.6)<.001
    Access, days<.001
        0–3491 (34.0)487 (48.3)
        >31,146 (66.0)521 (51.7)
    Rating<.001
        Very poor106 (6.2)17 (1.8)
        Poor241 (14.2)76 (8.0)
        Fair461 (27.1)202 (21.2)
        Good398 (23.4)242 (25.4)
        Very good290 (17.1)219 (23.0)
        Excellent203 (11.9)198 (20.8)
  • Table 3.

    Number of Problems to Discuss or Reason for Visiting a General Practitioner

    Problem CharacteristicsMost Deprived Areas n (%)Least Deprived Areas n (%)P Value
    No. of problems<.001
        1712 (47.7)545 (59.0)
        2559 (37.5)309 (33.4)
        >2221 (14.8)224 (7.5)
    Acute or chronic.093
        New problem451 (29.3)304 (29.4)
        Long-standing612 (33.2)393 (38.0)
        Both691 (37.5)336 (32.5)
    Nature of problem<.001
        Physical1127 (65.9)780 (78.2)
        Psychosocial295 (17.3)101 (10.1)
        Physical + psychosocial222 (13.0)94 (9.4)
        Administrative66 (3.9)23 (2.3)
  • Table 4.

    Characteristics of Clinical Encounters With a General Practitioner (GP) in the Most Deprived and Least Deprived Areas of Scotland, by Type of Consultation

    Consultations for Physical ProblemsConsultations for Psychosocial Problems
    CharacteristicMost Deprived Areas Mean (SD)Least Deprived Areas Mean (SD)P ValueMost Deprived Areas Mean (SD)Least Deprived Areas Mean (SD)P Value
    * Based on the General Health Questionnaire-12 caseness cutoff score of 4 or more.
    † Rated on a scale from 1 to 5, in which 1 = not at all, 5 = very well.
    ‡ Rated on a scale of 1 to 10, in which higher scores indicate higher empathy.
    § Rated on a scale of 1 to 6, in which higher scores indicate more enablement.
    || Rated on a scale from 0 to 10, in which 0 = no stress and 10 = very much stress.
    Age, years45.4 (17.9)47.5 (17.9).01539.5 (14.0)43.7 (14.8).003
    General health score*2.7 (1.0)2.4 (1.0)<.0013.22 (1.0)2.8 (1.0)<.001
    No. of problems1.6 (0.9)1.5 (0.7)<.0012.0 (0.9)1.7 (0.7).003
    Knows doctor†3.6 (1.4)3.5 (1.3).2853.8 (1.3)3.6 (1.2).127
    GP empathy score‡41.1 (0.9)40.6 (0.9).30040.9 (9.1)42.2 (8.6).156
    Consultation duration, minutes8.0 (4.0)8.4 (4.5).0458.9 (4.3)9.6 (4.9).076
    Patient enablement score§4.0 (3.8)3.9 (3.5).5553.3 (3.4)4.1 (3.5).023
    GP stress index||3.8 (2.4)3.3 (1.6)<.0013.9 (2.3)3.3 (1.5)<.001

Additional Files

  • Supplemental Appendix

    Supplemental Appendix. Sample Frame and Reliability of CARE Measure and PEI

    Files in this Data Supplement:

  • The Article in Brief

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

    Stewart W. Mercer, MBChB, PhD , and colleagues

    Background The inverse care law states that good medical care is least available where it is most needed. This study aims to learn more about the inverse care law by examining primary care doctor visits in the most and least deprived areas of Scotland.

    What This Study Found Patients in most deprived areas had more serious psychological problems, more long-term illness, and a greater number of medical conditions than patients in least deprived areas. Although patients in deprived areas had more problems to discuss, their doctor visits were usually shorter than in less deprived areas. General practitioners working in deprived areas were more stressed than those in the least deprived areas.

    Implications

    • The increased burden of ill health and multiple medical conditions in poor communities results in high demands on primary care doctor visits.
    • If the inverse care law is to be reversed, health care policies must address inequalities in public health by focusing on the primary care setting.
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