Commentary: What is the NHS for?

Abstract

challenge 'the conventional wisdom of inverse care'. 1 Analysing primary care data from England, they show that the mismatch between need and resource, resulting in inequitable access to health care, applies as much to the health needs of older populations as deprived populations, and is especially the case in populations that are both older and deprived. This is an important and, in places, a contentious paper, raising issues that may help to clarify what is meant by inverse care and how it should be addressed.Readers with long memories may be reminded of the Jarman deprivation score, which was pragmatically constructed to reflect what makes GPs busy, and thus included a measure of the numbers of older patients served. Concern about workload is also familiar to the GP negotiators of the British Medical Association whose traditional position has been that GPs should be similarly resourced and rewarded for being busy. However, there is more to the NHS than paying doctors, and keeping doctors busy is no guarantee of social justice.Asthana and Gibson observe that while almost everyone seems familiar with the 'inverse care law', there is little precise understanding of what it is and how it should be addressed. Tudor Hart's original paper contained few data and was principally concerned with the effects of market forces.2 More recent discussion has begun to tease out different definitions of access, according to structure, process, and outcome 3 and taking into account the increasing ability of health care to increase longevity. 4 By distinguishing 'public health and other preventive efforts' from 'curative care', Asthana and Gibson appear to undervalue what can be achieved by the NHS, reversing risks and preventing complications in large numbers of people, as first demonstrated by Julian Tudor Hart. 5The desk-based analyses presented in the paper are similar to many in the last decade, trying to rationalise the distribution of NHS resources according to need. However, a clear picture remains elusive. Not only are general practice populations not geographical, but their social heterogeneity, both within practices, and between practices within geographical areas, makes it difficult to focus on areas of the NHS where needs are greatest. Studies based on 100% of practices are also hampered by the limited availability of quality data. For example, although the Quality and Outcomes Framework (QOF) provides prevalence and activity data for almost every practice in the country, the prevalence data are not broken down by age and the clinical activity data cover only the most measurable aspects of primary care.As Asthana and Gibson report, QOF data do allow some estimation of the multiple morbidity associated with ageing, in which individual patients tend to have several clinical diagnoses. Much less information is available to desk epidemiologists on the multiple morbidity typically associated with deprivation, which is made up of the number, severity, and complexity of health and social problems within families.In the abse...