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Is the inverse care law no longer operating?
  1. Jean Adams,
  2. Martin White
  1. School of Population and Health Sciences, University of Newcastle upon Tyne, The Medical School, Newcastle upon Tyne NE2 4HH, UK
  1. Correspondence to:
 Dr J Adams
 j.m.adamsncl.ac.uk

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The inverse care law, proposed by Julian Tudor Hart in 1971, states that “the availability of good medical care tends to vary inversely with the need for it in the population served.”1 A number of authors have now claimed to have found instances of the inverse care law operating in practice.2,3 Given the prominence that this “law” has gained in the healthcare literature over the past 30 years, we were surprised to note that Jordan et al failed to make reference to it in their recent article on the relation between access to services and health.4

In this report, access to services was measured as both straight line distances and car travel time to the nearest GP surgery and hospital as well as the access domain of the index of multiple deprivation 2000, which combines measures of straight line distances to the nearest general practitioner, primary school, food shop, and post office. Among urban wards, the authors report a consistent inverse association between distance to services and both mortality and limiting long term illness (LLTI) in people aged 0–64 years—although this association was negligible in terms of the relations between LLTI and distance to hospitals.

Both premature mortality and LLTI are markers of need for health services in themselves. In addition, they are both strongly associated with deprivation in the UK,5 and therefore a much broader marker of need for health services. The results of Jordan et al suggest that areas with greater need for health services are nearer to and have greater access to, or concentration of, both health and wider social services. This is in conflict with the inverse care law, which would predict that distance to services should be greater, and therefore access poorer, in areas with higher levels of need.

Are the results of Jordan et al evidence that the inverse care law is no longer operating in the UK? Is it possible that over the past 30 years, we have managed to redistribute primary care services, in particular, so equitably that instead of deprivation, poor health and greater need for services being associated with poor access to services, it is now associated with greater access to services? Alternatively, is it possible that the inverse care law has rarely operated in practice in the UK in recent times and that “evidence” for it has misinterpreted the original formulation of the law and focused on use of services, rather than provision of them?2

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